SOAP NOTE 1 OB/ POLYCISTIC OVARIAN SYNDROME.

REVIEW OF SYSTEMS:

CONSTITUTIONAL: Denies fever, chills or malaise. Denies low energy in the past two weeks as identified in the PHQ-9 questionnaire. Denies weight loss, change of appetite.

NEUROLOGIC: Denies headache, changes in LOC, history of tremors or seizures, weakness, numbness, dizziness, headaches. Denies trouble walking, syncope, sleep disorder, memory problems.

PSYCHIATRIC: Mood was euthymic, not feeling restless or anxiety. No feeling hopelessness or depressed. No sleep disturbances, trouble falling or staying asleep. Normal enjoyment of activities. Not easily distracted and no change in thought patterns.

HEENT: Head: Denies head injuries, or change on LOC. Eyes: No irritation, no drainage, no dry eyes, no pain on eyes’ structures or retro-orbital, no vision changes, no diplopia, or blurred vision. Ears: Denies loss of hearing, no ear pain, no drainage, no sensation of ears feeling full, no ear ringing, or ears’ trauma. Nose: Denies nasal congestion, no nasal drainage, no nosebleeds, and normal smell sense. Throat/Mouth: Denies sore throat, no hoarseness, no difficulty swallowing, or postnasal drip. No mouth sore, no thrush, no bleeding gums, no lips sore, no teeth problems.

NECK: Denies neck pain, no masses, no nodules, no history of thyroid abnormality.

RESPIRATORY: Denies chest congestion or wheezing, coughing, shortness of breath.

CHEST/ BREAST: Denies chest abnormalities, no breast lumps, no nodules, no nipple drainage, or nipple retraction.

CARDIOVASCULAR: Denies chest pain, palpitations. No orthopnea, or paroxysmal nocturnal dyspnea. Denies edema, irregular heartbeat, low or high blood pressure, poor circulation, cold extremity, or claudication.

GASTROINTESTINAL: Normal appetite as identified in the PHQ-9 questionnaire. No dysphagia or heartburn. No nausea, vomiting or abdominal pain. No hematochezia. No diarrhea or constipation.

GENITOURINARY: Denies dysuria, frequency, urgency, hesitancy, incontinence, nocturia, or

hematuria. No history of UTI and kidney infections

EXTERNAL GENITALS: The patient reports watery, bloody vaginal discharge for 2 weeks

and mild discomfort over the pelvic area. No history of STD.

MUSCULOSKELETAL: Denies fall, muscle or joint pain. Denies hearing a clicking or snapping sound. Denies numbness, hemiplegia o paresthesia, muscular atrophy or weakness. Denies limited range of mobility, joint pain or limited ROM.

HEMATOLOGIC: Denies easy bruising, loss of hair, heat/cold intolerance, changes in nails, enlarged glands, prolonged bleeding, increased thirst, or hunger.

SKIN: Denies skin rash, no wound, no change on skin color or texture, no change in a mole, no unusual growth, no dry skin, no itching, or jaundice. Hair: Denies hair loss, no hair abnormalities. Nails: Denies nails abnormalities, no discoloration, no clubbing, no cyanosis, or longitudinal ridges.

OBJECTIVE DATA:

VITAL SIGNS: Temperature: 97.9 F0, Pulse: 86 BPM, BP: 123/77., RR: 18 per min.

PO2- 98 % on room air.

Gynecological examination was performed in the office.

GENERAL APPEARANCE: Patient alert and oriented. Speech fluently. Patient does reflex discomfort in her face and posture secondary to the pain on her genitals

NEUROLOGIC: Alert, CNII- XII grossly intact, Oriented to person, place and time. Sensation: Intact to Bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. Romberg is negative and the patient has stable and balance gait. Reflexes 2 + symmetrical with negative Babinski. No asterixis. Proprioception was normal

PSYCHIATRIC: Cooperative but stressed about her genital condition. Patient is euthymic. The affect was normal.

HEENT: HEAD: Normocephalic, atraumatic. Symmetric, nontender. Maxillary sinuses, no tenderness. Scalp pink and dry. EYES: No conjunctival secretion or injection, no icterus, extraocular eye movement intact. No nystagmus noted. Symmetrical pupils, light reactive, Visual acuity 20/20 with the use of reading glasses. EARS: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. NOSE: Nasal mucosa moist without bleeding. Clear nasal discharge. MOUTH AND THROAT: Oral mucosa moist without internal lesions such as canker sores, ulcers or vesicle. Tongue and uvula movement preserved without deviations.

NECK: No pain, no cervical lymphadenopathy, no jugular vein distention the palpation thyroid is mobile when the patient swallows, centrally located without evidence, or increased in size, trachea is midline. No murmur at the level of the carotid arteries. No visible mass and skin with normal coloration. No palpable masses or tenderness, thyroid without nodules, no JVD, no lymph nodes. Pharynx: Moist and pink without tonsillar enlargement. No noted lesions or exudate.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no S3 or S4, no murmurs or gallop noted, PMI at 5th intercostal space, midclavicular line. No pericardial friction rub heard.

All pulses 4+ palpable and equal. No clubbing, cyanosis or edema noted. Bilateral carotid arteries without bruits. Capillary refill test < 2 sec.

RESPIRATORY: Respirations are regular, equal, and unlabored with symmetrical chest expansion. No egophony whispered pectoriloquy, or tactile fremitus, on palpation. Breath sounds presents and clear bilaterally, on auscultation. No wheezing, stridor, crackles, or rhonchi noted. No increased tactile fremitus noted. Lungs resonant.

CHEST: Breast: Normal in size. Symmetric. Two normal nipples without discharge. No skin changes (rashes, lesions, dimpling or retraction). No masses or tenderness.

GASTROINTESTINAL: Inspection: Symmetric, no distended no visible masses. The skin

is normal, appendectomy 4 cm scar located on RLQ. Auscultation: Bowel sound active in all 4

quadrants. No bruits. Palpation: Abdomen soft, mild tenderness on lower abdomen, non

distended, no masses, herniation, guarding, rebound tenderness. No hepatomegaly or

splenomegaly. Percussion: Normal.

GENITOURINARY:

External genitalia: Mons normal hair distribution, no lesions. Labia majora, minora and

clitoris normal. Bartholin’s and Skene’s glands normal. Urethra WNL.

Vagina: Rugate, pink/red, inflamed wall, no discharge, good tone, no cystocele,

rectocele or masses.

Kidneys: Both kidneys have normal size, they are not palpable. Costovertebral angles are

not tender on palpation and percussion. The bladder is not palpable or tender.

Cervix: Small, no lesions, masses, inflammation, bloody discharge, negative for cervical

motion tenderness, no ectropion.

Uterus: Big firm, lateral, hard and not mobile, tender to motion.

Adnexa: Thickness of right parametrium. Ovarium not palpable.

MUSCULOSKELETAL: No evidence of atrophy, tumor. No pain to palpation. Active and passive ROM within normal limits, no stiffness. No peripheral edema. Stable gait.

INTEGUMENTARY: Intact, no cyanosis or jaundice, Nail without alterations: no mycosis, angle 160 degrees (no clubbing). Hair distribution in the preserved leg area, no area of paleness or redness, symmetrical calf diameter.

ASSESSMENT:

Main Diagnosis: Postmenopausal bleeding. ICD 10 N95.0-). Postmenopausal bleeding: refers to any uterine bleeding in a menopausal woman, it occurs on 5% of the postmenopausal population, and between 6-19 % is due to Endometrial cancer. In general, all postmenopausal women with unexpected uterine bleeding, should be evaluated for endometrial carcinoma, which is a lethal disease cause of bleeding, however, the most common cause of bleeding in these women is atrophy of the vaginal mucosa or endometrium; in the early menopausal years, endometrial hyperplasia, polyps, and submucosal fibroids are also common etiologies. (Goodman et al 2021). This patient present to the office after her menopause years ago, with symptoms, signs, and physical examination correlated with Post-menopausal bleeding. We must rule out the Endometrial Carcinoma as a cause of postmenopausal vaginal bleeding, discomfort on lower abdomen.

Also, the positive findings at bimanual vaginal examination of big firm, hard, lateral uterus, not mobile, tender to motion, thickness of right parametrium place that option the first in line.

The Differential diagnosis are with:

Cervical polyps: The cause is unknown, but inflammation play an etiologic role, the

principal symptoms are discharge and abnormal vaginal bleeding, the polyps are visible in the

cervical os on speculum examination. (Papadakis &amp; McPhee, 2017)

Post-coital vaginal laceration: Appears frequently in postmenopausal women with

atrophic vagina due to low levels of estrogens. It is not uncommon to experience some amount

superficial trauma or tears to the vagina especially after a lengthy session of intercourse. It is

usually, painless. However, at times, the trauma to the vagina can be quite extensive, requiring

emergency intervention (Domino, 2017).

Atrophy of the endometrium and vagina: Secondary to the hormonal changes of the

menopause the hypoestrogenism could cause changes included atrophy of the endometrium and

vagina. It produces micro erosions of the epithelium, associated to chronic inflammation, and it

facilitate the bleeding. Then during the examination, you can find a dry vaginal epithelium that it

is smooth and shiny with loss of most rugation. Then, the blood vessels could be visible, and

there is a chance of bleeding. (Goodman et al 2021).