Soap Note

Name: L.H

Date: 10/03/2018

Time: 11:00 AM

Age: 26 y/o

Sex: Female

SUBJECTIVE

CC: “I have been having fatigue, appetite changes, breast tenderness, and abdominal bloating two weeks before my menstrual period.”

HPI:  Patient is a 26-years-old Hispanic Female presents to the office c/o having fatigue, appetite changes, breast tenderness, and abdominal bloating two weeks before her menstrual period start for three to four days. Patient referred same symptoms are presents every month. She managed her symptoms with Tylenol with some relief. Gynecologic history menarche: 12 y/o with rhythm 28x5, denies any STDs, G0P0A0L0, sexually active, one partner.

Medications: No.

PMH: Denies

Allergies: Denies any allergies to food or medication

Medication Intolerances: Denies.

Major traumas: Denies any trauma

Hospitalizations: Denies hospitalizations

Surgeries: Denies

Family History

Mother: Alive, Healthy.

Father: Alive, HTN,CAD.

Brothers: 1 Alive HTN

Children: None.

Social History:

Home type: House

Marital status: Single

Religion: Christian.

Tattoos: no

Alcohol: Denies

Drugs: Denies

Smoker: Non-smoker

Exercise: 30 minutes of walk everyday

Pets: No

Travel: Denies.

Blood Transfusion: Denies

OBSTETRIC/GYNECOLOGICAL HISTORY: Single, sexually active, Heterosexual, denies STI's, Menarche: 10 y/o, LMP: 09/01/18 for 5 days, regular cycle, plus the spots already described, G0T0P0A0L0, Birth Control: Yes/ condom.

ROS

General

Denies any weight change in the last past 6 months, denies weakness, fatigue report monthly, not fever or chills. No distress noted at this moment, responding question in an appropriated mood. No exercise intolerance.

Cardiovascular

Patient denies chest pain and palpitation. No edema noticed no syncope, no orthopnea.

Skin

Warm and dry, skin is appropriated color for ethnicity.

Respiratory

Patient denies cough, dyspnea, wheezing or hemoptysis, no acute distress at this moment.

Eyes

Denies changes in vision, no blurred vision, no diplopia, no tearing, no scotomata, and no pain.

Gastrointestinal

No nauseas, no emesis, no dysphagia, no bowel habit changes, no melena, no constipation.

Ears

Denies ear pain, hearing loss, ringing in ears, discharge, pearly grey membranes.

Genitourinary/Gynecological

Denies dysuria, frequency or urgency. Denies blood in urine. No urinary urgency, no change in nature of urine. No vaginal discharge.

Nose/Mouth/Throat

Denies difficulty in smelling, sinus problems, nose bleeds or discharge. Denies dysphagia, hoarseness, or throat pain.

Musculoskeletal

Denies cramps, joint stiffness, arthritis or gout, limitation of movement, history of musculoskeletal or disk diseases; denies any muscle or joint pain.

Breast

Tenderness, denies pain, rash, discomfort, alteration of nipples, or swelling, breast lumps, no nodules, no nipple drainage, no nipple retraction or axilla.

Neurological

Denies history of headaches, syncope, seizures, stroke, memory disorder or mood change. No weakness, paralysis, numbness/tingling, tremors or tics, involuntary movements, or coordination problems. No mental disorders or hallucinations.

Heme/Lymph/Endo

Denies easy bruising or bleeding. No history of anemia, blood transfusions or reactions. Denies exposure to toxic agents or radiation. / Denies heat or cold intolerance, excessive sweating, polydipsia, polyphagia, or polyuria. No history of diabetes, thyroid disease, or hormone replacement.

Psychiatric

Denies depression, memory changes. Denies suicides attempts or thoughts. No history of mental illness.

OBJECTIVE

Weight 134 lbs   

BMI: 21.6

Temp 98.0 F

BP 112/60 mm/Hg

Pain: 0/10

Height 5’6’’ inch

Pulse 78 bpm

Resp 18 bpm

O2 Saturation: 99 % at Room air

General Appearance

Patient is a 26 y/o WHF, appearing of staged age; Alert and oriented; answers questions appropriately. No acute distress at this time. AAOX4, PERRLA; answers questions appropriately. Pain level: 0/10 on scale of pain.

Skin

General appearance is normal. Normal temperature, Hydrated, no rashes or lesions described. Intact, warm, moist, good turgor. Screening for skin cancer performed no precancerous skin lesion.

HEENT

Head normocephalic, atraumatic and without lesions; hair evenly distributed. Throat: Pharynx mildly erythematous, no exudates. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa edematous, clear rhinorrhea, moderate airway obstruction. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist.

Cardiovascular

No murmur, no rubs or gallop upon auscultation.

Capillary refill 2 seconds. Regular rhythm and rate with S1, S2 normal, no S3 or S4

No edema.

Respiratory

Symmetric chest wall. Lungs: bilateral mildly, lungs clear upon auscultation, no rales, and no wheezes. Breath sounds equal, no rubs. No respiratory distress noted at this time.

Gastrointestinal

Abdomen Soft, non-tender, BS normal in all 4 quadrants. No hepatosplenomegaly, mass, or herniation

Breast

Only reported tenderness, no change in texture, contours or appearance. Exam performed with a female nurse present. There is no axillary adenopathy or tenderness. Breasts appear to be symmetric. There was no nipple discharge or retraction. No breast tissue retraction noted in either the sitting or the supine position. Upon palpation, there were no palpable lumps or bumps and no palpable discharge.

Genitourinary

Genitalia:

Normally developed female genitalia. No perineal or perianal abnormalities are seen. No genital lesion or urethral discharges. No noted introitus discharge or irritation.

Speculum examination: No vaginal walls bleeding, no cervix discharge, erythema, punctate hemorrhages (strawberry-patch cervix), or friability. Bimanual examination: Mobile cervix, not painful. No adnexal masses or tenderness. No pelvic pain.

Musculoskeletal

Steady gait, no limping or musculoskeletal deformities, or muscular atrophy. Thoracic and lumbar spine, normal. Full ROM in all 4 extremities, no joint stiffness.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; normal gait.

Reflexes 2+ bilaterally throughout.

CN II-XII intact.

Psychiatric

Good judgment. Alert and oriented. Dressed in clean skirt and blouse. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab /Tests/Screening/Intervention/Assessment:

CBC, BMP, PT/INR, PTT, Vaginal culture, Pelvic and Transvaginal Sonogram.

Intervention

1. Calculated BMI / in normal parameters

2. Counseling about physical activity (exercise)

3. Pain severity 0/10

4. Documentation of current medications (procedure)

5. Adult depression screening assessment

Special Tests

 Not performed.

 Diagnosis

1. Premenstrual Syndrome due Clinical Presentation and Physical exam.

1. Premenstrual Syndrome (ICD 10: N94.3)

Premenstrual syndrome (PMS) is characterized by irritability, anxiety, emotional lability, depression, edema, breast pain, and headaches, occurring during the 7 to 10 days before and usually ending a few hours after onset of menses. (Merck Sharp & Dohme Corp 2017).

DIFFERENTIAL DIAGNOSTIC:

1. Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features such as a typical facial appearance, hoarse slow speech, and dry skin and by low levels of thyroid hormones (Merck Sharp & Dohme Corp 2017)

2. Endometriosis is a functioning endometrial tissue is implanted in the pelvis outside the Uterine cavity. Symptoms depend on location of the implants and may include dysmenorrhea, dyspareunia, infertility, dysuria, and pain during defecation. Severity of symptoms is not related to disease stage (Merck Sharp & Dohme Corp 2017)

Plan/Therapeutics & Education:

Pharmacologic treatment: 

1. Antidepressants (SSRI or SNRI).

2. Fluoxetine 20 mg q AM

3. Oral contraceptive pills (OCP).

4. Dietary supplement trial for 3months.

5. Calcium Carbonate 1200 mg per day throughout cycle.

6. Vitamin B6 100 mg daily throughout cycle.

Teaching/Education:

Daily symptoms diary.

Dietary changes (avoid caffeine, alcohol).

Importance to maintain Hand Hygiene, General Hygiene. Diet habits and life style modification Healthy diet, Normal calorie diet or fat, increased fiber and vegetables in diet. Increase physical activity.

Relaxation techniques.

Cervical cancer screening should begin approximately 3 years after a woman begins having vaginal inter- course, but no later than 21 years of age. Screening should be done every year with conventional Pap tests or every 2 years using liquid-based Pap tests.

Follow-ups/Referrals:

* Patient need to return to clinic if there is no improvement after 48 hours of treatment, or sooner if their condition is worsening.

* Follow Dr. orders and in case of emergency please call 911 or come to nearest ER.

* Follow up in two weeks to evaluated patient and laboratory testing results.

* No referrals needed at this time.

References:

Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia, Pa: Elsevier; 2006.

Merck Sharp & Dohme Corp., Inc., Kenilworth, NJ, USA (2017), Retrieved from http:// www.merck.com/

 Evaluation of patient encounter:

Interview process went well, practitioner elaborated the plan of care with patient, and education was provided and verbalized understanding.