I Need two Responses Per Each Discussion(soap note) Total 6 Responses. Attached Are The Discussions(soap Note) .One Reference Per Each Discussion
PATIENT INFORMATION
Name: M.E
Age: 30
Sex: Female
SOURCE: Patient
CHIEF COMPLAIN: " Patient had discharge with blood, she went to the hospital yesterday for left pelvis pain and inflammation "
HISTORY OF PRESENT ILLNESS: Patient came because she went to Hospital ER yesterday because of pelvic pain and irregular menstrual cycles. A TVS done showed a 5.7 cms left ovarian cyst. (evidence shown by printed results.) Sexually active refers to PCB and vaginal itching sometimes.
PAST MEDICAL HISTORY:
Hypertension: Y - Dx 2018 on medication
Congenital atresia of the tricuspid valve - Onset: 09/18/2018
GYN History
Reviewed GYN History
Age at Menarche: 12.
Date of LMP: 09/01/2020
Menses Monthly: Y.
Flow: Heavy (Notes: with clots).
Date of Last Pap Smear: 09/18/2019 (Notes: Negative for intraepithelial lesion or malignancy.).
Abnormal Pap: N.
HPV Vaccine: N.
Sexually Active?: Y.
Sexual Problems?: N.
STIs/STDs: No.
Age at First Child: 23.
Current Birth Control Method: Condoms.
Surgical History
Reviewed Surgical History
C-Section - 08/19/2013
Other - 01/01/1990 - Heart Surgery and 01/01/1991 and 01/01/2002
CURRENT MEDICATIONS:
Sprintec (28) 0.25 mg-35 mcg tablet
Take 1 tablet(s) every day by oral route for 28 days.
01/30/18 prescribed Yeissen Godinez
ALLERGIES:
ASPIRIN: Respiratory distress (Severe)
IODINE: Respiratory distress (Severe)
MORPHINE: Other (Severe) - lower her heart function
FAMILY HISTORY:
Mother: - Hypertensive disorder (onset age: 62)
- Asthma (onset age: 62)
Father: - Hypertensive disorder (onset age: 65)
SOCIAL HISTORY: Refers she is a social drinker, denies uses of any drugs, never smoker, consumes American coffee 2-3 times per day, works in a school. Lives with her husband and son. Denies any history of psychiatric diseases.
REVIEW OF SYSTEMS:
CONSTITUTIONAL SYMPTOMS: Denies fever or distress.
HEENT: Denies blurred or double vision, vision change, flashing lights, eye discharge, eye pain, irritation.
Ears, Nose, Mouth, and throat: Denies hearing loss or tinnitus, or pain. Nasal congestion. No drainage, redness, or swelling reported. Denies any throat pain.
Neck: Denies lumps or swollen glands, pain, or neck stiffness
CARDIOVASCULAR: Denies chest pain, SOB, or lightheadedness along with any palpitations at this time.
RESPIRATORY: Denies any SOB, congestion, or production of sputum.
GI: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Patient reports having daily bowel movements.
GU: Denies urgency, dysuria, or hematuria.
INTEGUMENTARY: No rashes, dryness, color change. No abnormalities of hair or nails.
MUSCULOSKELETAL: Denies stiffness, joint swelling, and decreased range of motion, crepitus, or functional deficit.
NEUROLOGICAL: Denies headaches, dizziness, or vertigo. Denies numbness, paresthesia, or tremors. No change in bowel or bladder control.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINE: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
HEMATOLOGIC/LYMPHATIC: Denies bruising or bleeding. No prior blood transfusions. No enlarged nodes. No history of splenectomy.
ALLERGIC/INMUNOLOGIC: No known allergies.
OBJECTIVE
Vitals & Measurements:
HT:5 Ft 1 inch Wt:139 Lbs. 26.3 09/17/2019 02:00 pm
BP:112/85 BMI:26.3
RR: 18 Pulse:112 Bpm
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: Well appearing, well-nourished, in no distress. Ambulating without difficulty.
HEENT: Head: Forehead and facial flushing. Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring.
Eyes: Lacrimation. Eyelid edema. Ipsilateral forehead flushing, ipsilateral conjunctival injection. Visual acuity is intact. Sclera non-icteric, EOM intact, PERRL, fundi have normal optic discs and vessels, no exudates or hemorrhages
Ears: EACs clear, TMs translucent & mobile, ossicles normal appearance, hearing intact.
Nose: Ipsilateral Nasal discharge. No external lesions, mucosa non-inflamed, septum, and turbinate’s normal
Mouth: Mucous membranes moist, no mucosal lesions.
Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant resorption. Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate
Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender
LUNGS: Clear sounds to auscultation and percussion.
HEART: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop.
BREAST/GENITAL:
Breast- No gynecomastia, nipples symmetrical. No skin changes, nipple discharge, retraction, lesions, masses, or tenderness appreciated on the exam. No lymphadenopathy in the axillary region bilaterally.
External genitalia-
Mons pubis-no lesions, pubis hair in a normal distribution.
Vulva/Labia Majora- no rashes, lesions, irritation
Bartholin Glands-no masses, inflammation, or discharge.
Skene glands- no masses, inflammation, or discharge.
Urethra-No prolapsed, discharge, non-tender.
Bladder-Unappreciated on exam
Vagina- no lesions, no discharge or blood, strong muscular tone, there was discomfort during the insertion of the speculum into the vagina.
Cervix-Squamocolumnar junction identified on the exam. No erythema or lesions appreciated on exam.
Uterus- midline, firm, mobile, non-tender with movement.
Adnexa-no masses, non-tender bilaterally.
Rectal-patient deferred rectal exam at this time.
ABDOMEN: No rebound, guarding, pulsating mass, or bruits. Bowel sounds are active. No palpable hernias throughout the abdomen.
EXTREMITIES: No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses Intact.
NEUROLOGIC: Sensorium appears grossly intact. Norm reflexive.
PSYCHIATRIC: No depressive symptoms, nervousness, or changes in sleep.
DERMATOLOGIC: Skin is uniform in color, unblemished, good skin turgor and skin's temperature is within normal limit.
Hair: Normal texture and distribution.
Nails: Normal color, no deformities.
MUSCULOSKELETAL: Normal gait and station. No misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, decreased range of motion, instability, atrophy, or abnormal strength or tone in the head, neck, spine, ribs, pelvis, or extremities.
HEMATOLOGIC/LYMPHATIC/ INMUNOLOGIC: No lymphadenopathy, no bruising, or erythematous areas.
Lab Tests:
US, TRANSVAGINAL -
Note to Imaging Facility: 30 y/o with left ovarian cyst 5.7 cms for follow up post-treatment.
COMPREHENSIVE METABOLIC PANEL
DIAGNOSIS:
Primary Diagnosis:
Primary Diagnosis:
ICD-10 N83.02 Follicular cyst of left ovary Cyst of ovary - 5.9 cm: There are two types of functional cysts: Follicular cyst. Follicular cysts are also known as benign ovarian cysts or functional cysts. Essentially they’re fluid-filled pockets of tissue that can develop on or in your ovaries. They commonly occur in women of reproductive age, as a result of ovulation. It’s rare for prepubescent girls to develop follicular cysts. Postmenopausal women don’t get them at all. Any cyst that occurs in a woman after menopause needs to be evaluated. Most follicular cysts are painless and harmless. They are not cancerous. They often resolve on their own, within a few menstrual cycles. You may not even notice you have a follicular cyst. In rare cases, follicular cysts can lead to complications that require medical attention. . ( Rajendran, S., & M Sankareswaran, U. (2016).
DIFFERENTIAL DIAGNOSIS
ICD-10 E28.2 Polycystic ovary syndrome (PCOS) is a hormonal disorder common among women of reproductive age. Women with PCOS may have infrequent or prolonged menstrual periods or excess male hormone (androgen) levels. The ovaries may develop numerous small collections of fluid (follicles) and fail to regularly release eggs. (McCartney, C. R., & Marshall, J. C. (2016)
ICD-10K66.8 Peritoneal inclusion cysts are complex cystic adnexal masses consisting of a normal ovary entrapped in multiple fluid-filled adhesions. The cysts usually develop in women of reproductive age who have a history of previous pelvic surgery or pelvic infection. (Rapisarda, A. M. C., Cianci, A., Caruso, S., Vitale, S. G., Valenti, G., Piombino, E., & Cianci, S. (2018)
ICD-10 N83.53 Ovarian torsion: Is a condition that occurs when an ovary twists around the ligaments that hold it in place. This twisting can cut off blood flow to the ovary and fallopian tube. Ovarian torsion can cause severe pain and other symptoms because the ovary is not receiving enough blood. If the blood restriction continues for too long, it can lead to tissue death. Symptoms of ovarian torsion can include the following: an adnexal or pelvic mass, nausea, severe pelvic pain, vomiting, abnormal bleeding, and fever. ( Huang, C., Hong, M. K., & Ding, D. C. (2017)
PLAN:
MEDICATIONS: Sprintec (28) 0.25 mg-35 mcg tablet -
Take 1 tablet(s) every day by oral route for 28 days
ADDITIONAL DIAGNOSTIC TESTS ORDERED: Ultrasound ordered.
EDUCATION: Educated about findings on the ultrasound, there are different kinds of ovarian cyst, most of them are cycle or functional related and expected to be self-limited. educated about how the cyst may affect her health, the appropriate follow up, the considerations (appearance in sonography, size), and possible treatment options also discussed. reevaluation in 2-3 months is advised.
She was told based on a previous study done at the same ER "she has a rapidly growing cyst".
The cyst is the benign appearance on description, reassurance given, treat with BCP, although she has hx of smoking. (refer hasn't smoked for some time), treatment ordered because she is symptomatic and for a short period of time.
Menses chart and detailed documentation of bleeding patterns.
Use condoms for protection, pregnancy, and /or STD.
FOLLOW UP:
Patient will return in two months. Reevaluate after Tx with f/u ultrasound.
References
Rajendran, S., & M Sankareswaran, U. (2016). A novel pigeon inspired optimization in ovarian cyst detection. Current Medical Imaging, 12(1), 43-49.
McCartney, C. R., & Marshall, J. C. (2016). Polycystic ovary syndrome. New England Journal of Medicine, 375(1), 54-64.
Rapisarda, A. M. C., Cianci, A., Caruso, S., Vitale, S. G., Valenti, G., Piombino, E., & Cianci, S. (2018). Benign multicystic mesothelioma and peritoneal inclusion cysts: are they the same clinical and histopathological entities? A systematic review to find an evidence-based management. Archives of Gynecology and Obstetrics, 297(6), 1353-1375.
Huang, C., Hong, M. K., & Ding, D. C. (2017). A review of ovary torsion. Tzu-chi Medical Journal, 29(3), 143.