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

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DEMOGRAPHIC INFORMATION

Name: Mrs. R. R.

Age: 28-year-old

Race: Hispanic.

Insurance: Medicaid.

Advance directives: yes, since 01/22/2020.

Subjective Data:

CC: “I’m have pain before and during my menstruation”.

HPI: Female patient, 29 years old, white, Hispanic, who comes to consultation referring to having pains before and during menstruation, often begins several hours before or just after menstrual flow, feels cramps occasionally and in some occasions lower abdominal pain constant, which radiates to the back or thigh. It is not accompanied by fever, digestive disorders.

PMH: No

Sexual/Reproductive Hx: Last pap: 2018, Dec, negative result,

Breast, mammogram: none.

Menstrual periods: regular every 28 days.

G2P0T1A1L1,

Last menstrual cycle: 2 days ago. Menarche: at 11 years old.

Use of contraception: Condon. She is sexually active.

FPMHx: Father: Psychiatric disorder. Mother: Obesity and HTN.

Meds: None.

Allergy: NKDA.

Immunizations: TT 2017.

Diet: Regular

Exercise: None.

Hospitalization: Aug/2019 Cyst ovarian, surgical intervention.

Nutrition History: regular Diet.

ROS:

General: denies recent weight loss, 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.

GENITOURINARY: Denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, denies vaginal discharge, vaginal bleeding, or itching. Reports

Normal menstrual cycles, w/ pain and stressful days.

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 AND BREASTS: Denies easy bruising, skin redness, skin rash, hives, sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.

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

Objective

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

Vital Signs:

BP: 110/70 mmhg, P: 78 x min, RR: 16 x min, T: 98.0 F, SpO2: 100 %. Wt.: 158 p. BMI: 26.5. Pain scale: 2/10.

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

Cardio: 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

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

Genitourinary: No pain in CVA, no lesions, no discharge. The bladder is non-distended;

Vaginal exam: Normal external genitalia. Bi-manual examination display uterus smooth, no pelvic tenderness or signs of pregnancy. Ovaries non-palpable. Speculum: Vagina and Cervix healthy.

Assessment

ICD 10: N94.6; Dysmenorrhea, unspecified; Dysmenorrhea refers to the symptom of painful menstruation. It can be divided into 2 broad categories: primary (occurring in the absence of pelvic pathology) and secondary (resulting from identifiable organic diseases). Signs and symptoms: A complete history should include the following: Age at menarche, Menstrual frequency, length of period, estimated menstrual flow, and presence or absence of intermenstrual bleeding, Associated symptoms, Onset, duration, type, and severity of pain, as well as its relation to the menstrual cycle, external factors affecting the pain, Impact of dysmenorrhea on physical and social activity, Progression of symptom severity, Sexual and obstetric history; Clinical features of primary dysmenorrhea include the following: Onset shortly after menarche (≤≤6 months), Usual duration of 48-72 hours (often starting several hours before or just after the menstrual flow), Cramping or labor like pain, Background of constant lower abdominal pain, radiating to the back or thigh, Often unremarkable pelvic examination findings (including rectal).

DDx:

ICD 10: E27.40; Unspecified adrenocortical insufficiency; s a condition in which the adrenal glands do not produce adequate amounts of steroid hormones, primarily cortisol; but may also include impaired production of aldosterone (a mineralocorticoid), which regulates sodium conservation, potassium secretion, and water retention. Craving for salt or salty foods due to the urinary losses of sodium is common. Addison's disease and congenital adrenal hyperplasia can manifest as adrenal insufficiency. If not treated, adrenal insufficiency may result in abdominal pains, vomiting, muscle weakness and fatigue, depression, low blood pressure, weight loss, kidney failure, changes in mood and personality, and shock (adrenal crisis).[1]

ICD 10: N39.00; Urinary Tract Infection (UTI); is an infection that affects part of the urinary tract.[1] When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as a kidney infection (pyelonephritis). Symptoms from a lower urinary tract infection include pain with urination, frequent urination, and feeling the need to urinate despite having an empty bladder. Symptoms of a kidney infection include fever and flank pain usually in addition to the symptoms of a lower UTI. Rarely the urine may appear bloody.[2] In the very old and the very young, symptoms may be vague or non-specific

ICD 10: N80.9; Endometriosis; is a condition in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside it. Most often this is on the ovaries, fallopian tubes, and tissue around the uterus and ovaries; however, in rare cases it may also occur in other parts of the body.[2] The main symptoms are pelvic pain and infertility. Nearly half of those affected have chronic pelvic pain, while in 70% pain occurs during menstruation. Pain during sexual intercourse is also common.[3] Infertility occurs in up to half of women affected. Less common symptoms include urinary or bowel symptoms. About 25% of women have no symptoms. Endometriosis can have both social and psychological effects.

Plan

Test: USG Transvaginal indicated.

Medications:

Naproxen 500 mg 1tab PO initially, then 250 mg ½ tab PO q6-8hr or 500 mg PO q12hr

(long-acting formula); not to exceed 1250 mg/day on first day; subsequent doses should not exceed 1000 mg/day naproxen base.

Try dietary supplements. A number of studies have indicated that vitamin E, omega-3 fatty acids, vitamin B-1 (thiamin), vitamin B-6 and magnesium supplements might reduce menstrual cramps.

Education:

Treatment of primary dysmenorrhea is directed at providing relief from the cramping pelvic pain and associated symptoms that typically accompany or immediately precede the onset of menstrual flow.

Exercise regularly. Physical activity, including sex, helps ease menstrual cramps for some women.

Use heat. Soaking in a hot bath or using a heating pad, hot water bottle or heat patch on your lower abdomen might ease menstrual cramps.

Reduce stress. Psychological stress might increase your risk of menstrual cramps and their severity.

Start taking the pain reliever at the beginning of your period, or as soon as you feel symptoms, and continue taking the medicine as directed for two to three days, or until your symptoms are gone.

Hormonal birth control. Oral birth control pills contain hormones that prevent ovulation and reduce the severity of menstrual cramps. These hormones can also be delivered in several other forms: an injection, a skin patch, an implant placed under the skin of your arm, a flexible ring that you insert into your vagina, or an intrauterine device (IUD).

Patient stated she understood instructions and had no questions.

Follow up in 4 weeks.

Referral: No.

References:

Martino M, Pellegrino P (2017). "Magnesium in the gynecological practice: a literature review". Magnes Res. 30 (1): 1–7.

Brown J, Sangkomkamhang US, Barnes J, Seyfoddin V, Marjoribanks J (March 2016). "Dietary supplements for dysmenorrhoea". The Cochrane Database of Systematic Reviews. 3: CD002124.

Swaroop A, Bagchi D, Bishayee A (2017). "A small plant with big benefits: Fenugreek (Trigonella foenum-graecum Linn.) for disease prevention and health promotion". Mol Nutr Food Res. 61 (6): 156-77.

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