SOAP Note

Name: LC

 Pt. Encounter Number:

Date: 08/30/2019

Age: 35

Sex: Female

SUBJECTIVE

CC: 

 " I have been bleeding between my periods."

HPI:  35-years-old, female patient went to the clinic today worried about spotting between her menstrual cycles. This has been going on for about 3 months, and there are no apparent patterns to when the spotting happens. she does, however, mention that she thinks it is worse after she has intercourse. Her menstrual cycles occur regularly in 28-day intervals and last three to four days. Patient denies any history of STD and states she used condom as a contraceptive method and for protection. She is monogamous with her partner of eight years. Her last pap smears were a year ago showing negative results.

Medications: N/A

PMH

Allergies: Not Known Drug Allergies.

Medication Intolerances: None

Chronic Illnesses/Major traumas: N/A

Hospitalizations/Surgeries: negative

Family History

Pt’s mother is alive and has history of Hypertension and hyperlipidemia. Father suffers from COPD and her two siblings are alive and healthy.

Social History

Patient is heterosexual, has a monogamous relationship for the past eight years. Pt only drinks one or two cups of alcoholic beverages in important events, she use to drink coffee three times a day and denies smoking and drugs.

ROS

General

Good appearance, denies fatigue, fever and malaise.

Cardiovascular

Patient denies chest pain, palpitations, or history of heart murmur

Skin

Negative for skin rashes, delayed healing, bruising, or skin discoloration.

Respiratory

No presence of cough, wheezing, negative history of pneumonia

Eyes

No visual changes, blurred vision, or double vision.

Gastrointestinal

No complaints of abdominal pain, eating disorders, ulcers, constipation, or diarrhea

Ears

Denies ear pain, abnormal discharge, or tinnitus

Genitourinary/Gynecological

Patient denies frequency, burning or pain with urination. She also refutes history of sexually transmitted diseases. Last Pap exam 1 years ago with unremarkable result at this time. Patient refers spotting between her menstrual cycles.

GH: G2, Para 1, T1, A1, P0, L1.

Nose/Mouth/Throat

Denies sore throat, nose bleeds, sinus problems, or dental disease

Musculoskeletal

Negative for joint pain, neck stiffness, or back pain.

Breast

Denies presence of tumors , skin changes and nipple discharge.

Neurological

Denies history of seizures, transient paralysis, syncope, or black out spells

Heme/Lymph/Endo

No presence of swollen lymph nodes. Denies changes in appetite or heat/cold intolerance.

Psychiatric

Negative for depression, anxiety, or suicidal ideation

OBJECTIVE

Weight: 163 pounds   BMI:27.98

Temp: 96.4F

BP: 138/67

Height: 5’4’

Pulse: 74

Resp: 18

General Appearance

Well-developed and nourished in no distress. Pt has good appearance and maintain eye contact during the conversation. Overweight

Skin: no rashes, good turgor, RUE mid skin thickness, shiny, no erythema present.

HEENT

Head is norm cephalic, atraumatic and without lesions; hair evenly distributed.

Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection.

Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized.

Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.

Oral mucosa pink and moist. Pharynx is non-erythematous and without exudate. Teeth are in good repair.

Cardiovascular

Rate and rhythm are regular. No murmurs or gallops present.

Respiratory

Clear to auscultation bilaterally, No SOB, wheezes, crackles, or rales .

Gastrointestinal

Abdomen is soft, non-tender, and obese. Bowel sounds present in all quadrants

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Genitourinary

Bladder is non-distended; no CVA tenderness. Patient deferred rectal exam.  External genitalia: Unremarkable. Speculum examination: Reveals a cherry- red growth extending from the internal cervix into vaginal canal. On bimanual examination, it is appreciated as a mobile mass of approximately 1 cm of diameter.

Musculoskeletal

Symmetric, no presence of deformities. Peripheral pulses are normal and present.

Neurological

Balance stable, gait normal, posture erect, speech clear

Psychiatric

A&O ×3, answers questions appropriately and maintains appropriate eye contact during the assessment

Lab Tests:

CBC-BMP- (WNL).

Urinalysis done in office -Negative result.

Special procedures: Pap smears done- send to lab.

Special Test

.N/A

Diagnosis

Differential Diagnosis

ICD-10(N87.9): Micro-glandular Hyperplasia of the uterine cervix is characterized for a lesion in the endocervical mucosa often present in woman’s with history of contraceptives or pregnancy. And has a benign etiology.

ICD-10(R87.810) Squamous papilloma: is a benign solid tumor typically located on the ectocervix, it arises most commonly as a result of inflammation or trauma, grossly, the tumor is usually small, measuring 2-5 mm in diameter, this resembles a typical condyloma acuminate. The diagnosis is done by biopsy and is not applied to this patient. (Milner D, Danny A .2015)

ICD-10(D25.9) Leiomyomas: This benign neoplasm may originate in the cervix and account for approximately 8% of all uterine smooth muscle tumors, they are similar to tumors in the fundus, when located in the cervix, they usually are small like 5-10 mm in diameter, symptoms depend on size and location, and consist in excessive menstrual bleeding (menorrhagia, often cause anemia and may lead to infertility. the diagnosis is done by biopsy, so you cannot rule out completely until you have your result.

ICD-10(N80.9)- Endometriosis: When present in the cervix is usually an incidental finding, however, it may present as a mass or abnormal bleeding, particularly postcoital, grossly, it may appear as bluish -red or bluish- black lesion, typically 1-3 mm in diameter, symptoms may include pelvic pain that worsen during menstruation, painful intercourse, painful bowel movement or urination, infertility, the diagnosis is done by biopsy, so you cannot rule out completely until you have your result.

Final diagnosis:

ICD-10 (N84.1) Polyp of Cervix Uteri: Characterized as a common benign tumor lesion on the surface of the cervical canal, that can produce irregular menstrual bleeding and course asymptomatic. The most frequent symptom is intermenstrual bleeding as is refer for the patient. In another’s woman can be diagnosed due the abnormally heavy menstrual bleeding, vaginal bleeding in post-menopausal women, bleeding after sex and leukorrhea, diagnosis is done at pelvic examination show a red or purple projection from the cervical canal ,diagnosis is confirmed by a cervical biopsy which will reveal the nature of the cell present, In this case the Diagnosis of Polyp of Cervix Uteri is rule in by the positives data finding at physical exam and Biopsy is order for confirm the diagnosis.(Smith, Melanie M,2016)

PLAN including education

Patient will be scheduled for elective excision of the polyp.

Pt will be referral to Gynecologist for the procedure.

· Education

Patient education and supportive counseling was critical during this encounter.

First, the practitioner discussed with the patient the nature of her condition including the symptoms, pathophysiology, and characteristics of treatment. The patient was educated about that treatment consists of simple removal of the polyp and prognosis is generally good. Also patient was informed that around 1% of cervical polyps will show neoplastic change which may lead to cancer, the cause is uncertain, but they are often associated with inflammation of the cervix, they may also occur as a result of raised levels of estrogens or clogged cervical blood vessel Patient encourage to continue having protective sexual intercourse, and to perform her pap smears yearly.

Follow-up

The practitioner will schedule a follow-up appointment after polys removed

and biopsy result obtained.