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HOME MEDICATIONS: None

IMMUNIZATION STATUS: TT react 2015.

ALLERGIES: NKDA

HOSPITALIZATIONS: None

FAMILY HISTORY: Father: DM. Mother: healthy.

SOCIAL HISTORY: Denies use tobacco, drugs, and coffee, drink alcohol social.

Diet: Regular.

Exercise: 3-4 times x week.

OB/GYN:

Sexual/Reproductive Hx: Last pap: 2019/ Feb, negative result,

Breast, mammogram: never don. G2P1A1.

Menstruation: Irregular,

LMP: 1 weeks ago, w/ duration of 3 days. She is married; Sexually active, with the same partner 2 years ago.

REVIEW OF SYSTEMS:

General: General: denies recent weight loss or gain, fever, change in appetite or headaches. She has no chills, or night sweat.

HEENT: Eyes - Denies pain, redness, loss of vision, double or blurred vision, Ears, nose, mouth and throat. Denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, frequent sore throats, hoarseness, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing.

CARDIOVASCULAR: Denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at night or varicose veins.

RESPIRATORY: Denies chronic dry cough, coughing up blood, coughing up mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats.

GASTROINTESTINAL: Denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids.

BREASTS: Tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.

GENITOURINARY: Refers irregular bleeding, and pain 3 / 10 pain scale with menstruation, more intense in intercourse; Denies urinary incontinence, or frequent urination, for about 2 weeks; blood in the urine, cloudy or smoky urine, denies vaginal discharge, vaginal bleeding, or itching.

MUSCULOSKELETAL: Denies arm, buttock, thigh, or calf cramps. No joint or muscle pain. No muscle weakness or tenderness. No joint swelling, neck pain, back pain, or major orthopedic injuries.

SKIN: Denies easy bruising, skin redness, skin rash, hives, sensitivity to sun exposure.

NEUROLOGIC: Denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss.

OBJECTIVE

Vitals & Measurements:

BP: 120/80 mmhg,

P: 76 x min,

RR: 18 x min,

T: 97.9, F

SpO2: 100 %.

Wt: 155 pounds,

BMI: 26.0 oF

Pain scale: 3/10.

PHYSICAL EXAMINATION:

General survey: in no acute distress, well-nourished. Cooperative, normal speech, no distress noted

HEENT: Normocephalic. There is no evidence of eyes or ear problems. Neck: Full ROM. No JVD, no bruits, no masses, thyroid gland no visible, no palpable. negative lymphadenopathy

RESP: Normal appearance, symmetric. Lungs: Clear to auscultation, No rales, no cough, no shortness of breath

BREASTS AND AXILLAE: Breasts- no dimpling, no masses, axillae- no masses observed, no lymphadenopathy, nipple w/o alteration, no discharge.

CARDIOVASCULAR: Regular rate and rhythm, no gallop, no murmur, no edema, peripheral pulses present, no cyanosis, no tachycardia.

GI: abdomen soft, non-tender, non-distended, +BSx4, no masses

M/S: Full ROM, muscle strength 5/5, no pain.

NEURO: Awake, alert, and oriented x 3, responsive to verbal and tactile stimuli. No focalization

GENITOURINARY: no discharge. The bladder is non-distended;

Vaginal exam: Pink vagina, well pigmented, no secretions, several polyps of approximately 8 mm in diameter, cervix closed, healthy.

Vaginal touch is excluded.

DIAGNOSIS:

Primary Diagnosis:

Polyp of vagina ICD 10: N84.2; They often cause no symptoms. Where they occur, symptoms include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual bleeding (menorrhagia), and vaginal bleeding after menopause. Bleeding from the blood vessels of the polyp contributes to an increase of blood loss during menstruation and blood "spotting" between menstrual periods, or after menopause. If the polyp protrudes through the cervix into the vagina, pain (dysmenorrhea) may result.

DIFFERENCIAL DIAGNOSIS

Cystocele, unspecified ICD 10: N81.1; A cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Other may have trouble starting urination, urinary incontinence, or frequent urination. Complications may include recurrent urinary tract infections and urinary retention. Cystocele and a prolapsed urethra often occur together and is called a cyst urethrocele. Cystocele can

negatively affect quality of life. Causes include childbirth, constipation, chronic cough, heavy lifting, hysterectomy, genetics, and being overweight.

Vaginal prolapse ICD 10: N81.4; is the herniation of the pelvic organs to or beyond the vaginal walls. With minimal or stage 1 prolapse, a woman may be asymptomatic and not need any active intervention. As the prolapse progresses, women may experience vaginal fullness, lower back

pain, urinary or defecatory dysfunction, dyspareunia, and pelvic pain. As prolapse worsens, the vault becomes exteriorized with a palpable and visible bulge which may bleed from mucosal ulcerations.

Rectocele ICD 10: N81.6; Mild cases may simply produce a sense of pressure or protrusion within the vagina, and the occasional feeling that the rectum has not been completely emptied after a bowel movement. Moderate cases may involve difficulty passing stool (because the attempt to evacuate pushes the stool into the rectocele instead of out through the anus), discomfort or pain during evacuation or intercourse, constipation, and a general sensation that something is "falling down" or "falling out" within the pelvis. Severe cases may cause vaginal bleeding, intermittent fecal incontinence, or even the prolapse of the bulge through the mouth of the vagina, or rectal prolapse through the anus.

PLAN OF CARE:

1.Test ordered: U/A, CBC. USG

2.Vaginal estrogen cream 1%, Apply the cream 2 times a day, gently, just lubricate with your finger before having undergone ample personal hygiene. [Boon, Mathilde E].

3. Acetaminophen 325 mg 1 tab each 8 hrs for pain. PO

Education:

Make seating baths. Avoid lifting weights greater than 3 pounds. Do not practice physical exercises for now and if possible, not have vaginal intercourse. Patient stated she understood instructions and had no questions.

Follow up after gynecologist evaluation.

Referral: Gynecologist.

References:

Boon, Mathilde E.; Albert J. H. Suurmeijer (2016). The Pap Smear. Taylor & Francis. p. 87.

Zuber, Thomas J.; E. J. Mayeaux (2017). Atlas of Primary Care Procedures. Lippincott Williams & Wilkins. pp. 254–256.

Smith, Melanie N. (2016-05-10). "Cervical polyps". MEDLINE. Retrieved 2017-11-05.