I Need two Responses Per Each Soap Note Discussion Total 8 Responses. Posts Will Be A Minimum Of 100 Words, APA Format.One Reference Per Each Discussion

Top of Form

NAME: D.J

AGE: 39 years old

SEX: Female

ALLERGIES: No.

 

CURRENT MEDICATIONS: None PMHX: No.

All vaccines current. TT 2016. Influenza 2019.

 FAMHX: Father bronchial asthma, Mother: DM T TII.

SOCHX: Patient married, one daughter, works fulltime, no alcohol, no smoking, no drugs.

 Menarche: 11 years old

First Intercourse: 16 years old Last menstrual period:

G1; T1; P0; A0; L1

Contraception: Contraceptive pills

Last Pap Smear: in 2018 (October, negative)

Last mammogram: none

Colonoscopy: Never performed.

SUBJECTIVE:

CC: “I have red spots after having sex”.

HPI: Patient Hispanic 39 years old female who comes complaining recurrent vaginal bleedings that appears every time after sexual intercourses. The manifestations have been presented without pain, cramps, or pelvic heaviness, patient also denies dysuria, hematuria, or vaginal discharge. Denies vomiting, nausea, urogenital diseases, or gastric diseases.

ROS:

CONSTITUTIONAL: Well appearing, well nourished, in no distress. Oriented x 3.

 Ambulating without difficulty. Mood depressed with irritability.

 NEUROLOGIC: Denies changes in LOC. Denies history of tremors or seizures.

 HEENT: HEAD: Denies any head injury, or change in LOC. Denies any changes in vision, diplopia, or blurred vision. Denies pain in the ears. Denies loss of hearing or drainage. Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

RESPIRATORY: Denies any SOB, congestion, or production of sputum.

 CARDIOVASCULAR: Denies history of cardiac disease, abnormal EKG, or chest pain. Denies dizziness or fatigue.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, or diarrhea.

MUSCULOSKELETAL: No pain, no tenderness, adequate mobility.

GENITOURINARY/GYNECOLOGICAL

Postcoital vaginal bleeding, recurrent, no painful. No bad odor referred, no vaginal masses, no cramps.

No urinary alterations referred

OBJECTIVE:

Vital Signs:

 Blood pressure 110/76 mmHg

 Heart rate 85 x min.

Respirations 16, x min. Temperature 97.5, F.

Height 5,5”

 Weight 157 pounds,

 BMI 24.3 m2.

 Pain Scale: 0/10.

 NEUROLOGIC: Sensation intact to bilateral upper and lower extremities; Bilateral UE/LE strength 5/5.

HEENT: Head norm cephalic without evidence of masses or trauma. PERRLA, EOMs intact. No injected. Fundoscopic exam unremarkable. Ear canal without redness or irritation,

TMs clear, pearly, bony landmarks visible. No discharge, no pain noted. Neck negative for masses. No thyromegaly. No JVD distention.

CARDIOVASCULAR: S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

RESPIRATORY: Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal:

Abdomen soft, no tenderness, no mass to palpation, no visceromegaly, bowel sounds present in 4 quadrants.

INTEGUMENTARY: intact

 Cognitive or Behavioral: Awake, alert, appropriate, and well groomed.

  BREAST: Breasts are symmetric, no skin alterations, no protrusion, free from masses or tenderness,  no discharge, no dimpling, no adenopathy. Axillary area clear.

Genitourinary:

INSPECTION: External genitalia exam reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation.

Bimanual exam performed: Uterus is retroverted with normal shape and consistency, no painful to examination, no fullness or masses detected. Ovaries are non-palpable. A medium speculum was inserted, vaginal walls normal constitution. No blisters or other lesions noted.

Cervix is pink and parous with no apparent lesions. No drainage presents.

 

PRIMARY DIAGNOSIS:

N93.0 Postcoital and Contact Bleeding. This a condition characterized by vaginal bleeding after sexual intercourses and it can be associated with pain or not. The bleeding can be from the cervix, uterus, and other organs that are close to the vagina. This alteration can have multiples causes such as cervical cancer, infections, cervical polyps, traumas, menstrual

alterations, and coagulopathies (Wan et al., 2015).

DIFFERENTIAL DIAGNOSIS:

1. Polypof cervix uteri ICD 10; N84.1; Cervical polyps are small tumors that grow on the cervix. This condition can be totally asymptomatic, but also would be characterized by vaginal discharge, postcoital bleeding, bleeding after douching, after menopause, or between periods. This disease would represent anearly sign of cervical cancer, and early treatment can reduce the risk of malignancy (Nelson et al., 2015).

2. Inflammatory disease of cervix uteri ICD 10: N72; Cervicitis is a condition characterized by swelling of the tissue of the cervix. This disease is usually caused by sexual transmitted infections such as gonorrhea, chlamydia, herpes virus, trichomoniasis, and human papillomavirus. Others associated factors include insertion of pelvic devices like cervical caps or diaphragms, allergies to spermicides, latex condoms, and chemical exposure. Principal symptoms include pelvic pain, dyspareunia, vaginal bleeding, vaginal discharge, itching, and dysuria (Putman, 2016).

 

1. ICD10: C54.1 Malignant neoplasm of endometrium. This is a malignant condition characterized by an abnormal grow of cells in the endometrium, with the ability to spread to other organs and tissues in the body. The most common manifestation and first sign isusually vaginal bleeding that is not associated with menstruations, other symptoms include pelvic pain, dysuria, and dyspareunia (Sakuragi &Silverberg, 2014).

PLAN:

 

ORDERED:

 CBC, CMB, Lipid profile, TSH, PT, PTT, D-dimer, Sed Rate. Transvaginal USG

Performed in the office: Pap Smear, HPV, and Vaginal culture swaps.

EVALUATION / FOLLOW UP

Follow up in the office in 4 weeks with complementary test results.

EDUCATIONS:

Postcoital bleeding refers to bleeding that happens after types of sex that involve vaginal penetration. That means postcoital bleeding can happen after vaginal penetration by a penis, dildo, or a partner’s finger.

If you're having postcoital bleeding, you may also be experiencing abnormal uterine bleeding that isn't related to sex. Approximately 30 percent of women who bleed during sex also have other episodes of abnormal bleeding outside of their regular monthly period.

References

 

Nelson, A. L., Papa, R. R., & Ritchie, J. J. (2015). Asymptomatic Cervical Polyps: Can We Just Let Them Be? Women Health, 11(2), 121-126.

Putman, S. B. (2016). Cervicitis and Vulvovaginitis. Oxford Medicine Online. doi:10.1093/med/9780199976805.003.0038

Sakuragi, N., & Silverberg, S. G. (2014). Current approaches to endometrial cancer.

 

Current Approaches to Endometrial Cancer, 2-4. doi:10.2217/fmeb2013.13.331

 

Bottom of Form