soap note

Name: A.R

Date: 05/22/2018

Time: 10:00am

Age: 52

Sex: Female

SUBJECTIVE

CC: 

“Pain and discomfort during walking or sitting”

HPI: 

52-year-old Hispanic female member who came to the office with complaining of pain and discomfort during walking or sitting, pain started 3 days ago. Member is being taking acetaminophen as need for pain, somehow effective.

Medications:

Furosemide 20 mg One tab PO daily

Potassium chloride 10meq One tab PO daily

Tylenol 500mg OTC- as needed for pain

PMH: Hypertension and Osteoarthritis

Allergies: None

 Major traumas: She denied any major trauma

Hospitalizations/Surgeries: C section x 1

Family History

Father age 75 PMH: Diabetes Mellitus type II

Mother age 72 PMH: Peripheral neuropathy, osteoarthritis.

Social History:

Education level: College education

Occupational history: teacher

Marital status: married

Substance use/abuse. Member denies cigarette smoking, alcohol, or illicit drug consumption.

Safety status: Member feels safe at home, able to walk around the house without any assistance device, no concern about any hazards.

ROS

General:

Denies any fever, chills, or night sweats. No change in weight for past few months with no dietary or exercise changes.

Cardiovascular

 Denies chest pain, palpitations, orthopnea, edema, SOB.As per member, morning blood pressure was 125/75.

Skin

 Denies dry or itchy skin. No rashes, bumps, or sores. No bruises, no moles changing in shape color or size. No changes in hair or nails.

Respiratory:

 Denies waking up at night short of breath, no SOB on exertion, no cough, no pain on respiration. Denies hemoptysis, wheezing, or pleurisy. Denies having asthma, bronchitis, emphysema, pneumonia, or tuberculosis. She had Chest X Ray done last year due to a severe cold, results were negative.

Eyes:

Reports wearing reading glasses. Denies blurring, visual changes of any kind. Report last eye exam 8 months ago.

Gastrointestinal:

 Denies constipation, nausea or vomiting hepatitis, hemorrhoids, ulcers, black tarry stools. Last bowel movement was today. Denies abdominal pain, food intolerance or excessive belching or passing gas. Denies jaundice, live, or gallbladder trouble. Denies Hepatitis.

Ears:

 Denies any ear pain, no discharge noted. Mild cerumen

Genitourinary/Gynecological:

 Denied been sexually active, any abnormal vaginal bleeding. No breast complaints. Last Pap and mammogram were done in June of 2017 which were normal. Menopause at age 46. Gravida 2, para 2.

Nose/Mouth/Throat:

 She denied any problem with her mouth, nose and throat, Denies Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, or throat pain

Musculoskeletal:

Denies, joint swelling, stiffness or pain, fracture. Denies history of osteoporosis. No assistance to be transfer. Report lower back pain that sometime radiates to her right his of 3 in the scale of 10 Taking Tylenol 500mg OTC as needed for pain

Breast:

No lumps, bumps or abnormalities

Neurological:

Denies Syncope, seizures, transient paralysis, paresthesia. Denies any head injuries, near syncope or syncopal episodes, vertigo, seizures, headaches, numbness, paresthesia, tremor, gait instability, falls, or memory loss. Cerebellar function is intact. No neurological deficits.

Heme/Lymph/Endo:

Denies easy bruising, bleeding, or blood clots. Denies increased thirst, hunger, and cold or heat intolerance. Patient denies change in body hair growth, night sweats, or swollen glands.

Peripheral Vascular:

Denies leg cramps, numbness, and pain when walking. Denies any changes in the color of her fingertips or toes during cold temperatures/weather. Denies any swelling or tenderness.

Psychiatric:

Some Sleeping Difficulties but not always. Denies having depression, anxiety, or suicidal ideation/attempts.

OBJECTIVE

Weight:  154 lbs      BMI: 25.6

Temp: 97.7 F

BP: 133/70

Height: 5’5”

Pulse: 76

Resp: 20

General Appearance:

Member is very cooperative. She is a 52-year-old Hispanic female with appropriate affect. Patient is alert and oriented x4, no acute distress, able to make her needs known, answers questions appropriately, well-groomed. Wearing a long dress

Skin:

Skin is warm, dry, clean and intact. No rashes or lesions noted.

HEENT:

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

Eyes: PERRLA

Ears: tympanic membranes intact, no redness, no drainage

Nose: Nasal No septal deviation, moist no drainage

Neck: Supple. full ROM; no nodules, palpable, no JVD, Thyroid gland mild-line

Oral mucosa pink and moist.

.

Cardiovascular:

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. Pulse present in all extremities. No edema.

Respiratory:

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

Gastrointestinal:

Bowel Sounds active in all 4 quadrants. Abdomen soft, mild tenderness No hepatosplenomegaly. Denies constipation, nausea or vomiting hepatitis, hemorrhoids, ulcers, black tarry stools. Last bowel movement was today.

Breast:

Breast are symmetrically free from masses or wrinkling or discoloration of the skin. No signs of engorgement. Nipples are intact, no cracking, bleeding, or signs of infection. She denied any history of breast cancer in her family.

Genitourinary:

Externa genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. Vagina is pale pink with rugae, moisture level is normal, Ovaries are non-palpable. No breast complaints. Last pap smear and on and mammogram were done in October of 2017. Bladder is non-distended; no CVA tenderness. Upon examination, there is a medially protruding cystic structure at the inferior aspect of the labia majora, in the 5 o'clock position, crossed by the labium minus.

Musculoskeletal:

Patient is ambulatory with good balance and steady gait. Good muscle tone, ROM WNL. No kyphosis, scoliosis, or lordosis. No Pain noted during assessment.

Neurological:

Speech clear. Good muscular tone. Posture is erect. Balance stable

Psychiatric:

AAOx3, No sensory/motor deficits. Speech clear. Good tone. Posture erect. Balance stable; gait normal. Pinprick, light touch, position sense, vibration, and stereognosis intact, Romberg negative. Reflexes 2 + and symmetric with plantar reflexes down going.

Lab Tests:

Microscopy and culture of abscess material

Biopsy of vulval lesion 

CBC

Special Tests:

none

 Diagnosis

 Differential Diagnoses / Differential symptoms / Differential Test

1- Vulval lipoma: Skin-colored, soft, fatty tumor of the subcutaneous tissue; typically, asymptomatic, and slow growing. (Lynch & Edwards, 2014). Usually in the labia majora, and further lipomas may be found on lower abdomen or thighs. / Diagnosis is clinical. (Black, McKay & Braude, 2012).

2- Malignant lesion of Bartholin gland: Tends to present in older women (>50 years) as an irregular nodular vulval mass, with or without ulcerations. / Biopsy of the lesion confirms or excludes malignancy. (Dennerstein, Scurry &, Brenan, 2015)

3- Cyst of the canal of Nuck: Cystic swelling in the inguinal crease or anterior labia majora. Not crossed by the labium minus. Arises from remnants of peritoneum as it passes through the inguinal canal, so cysts may occur anywhere along the path of the inguinal canal or within the labia majora. / Diagnosis is clinical. (Dennerstein, Scurry &, Brenan, 2015)

Diagnostic:

Bartholin duct cyst

A Bartholin duct cyst is a noninfectious occlusion of the distal Bartholin duct with resultant retention of secretions. The paired Bartholin ducts are located at the posterior vestibule and provide a conduit for secretions from the Bartholin glands. A Bartholin duct cyst may be asymptomatic if the cyst is small. It typically presents as a medially protruding mass at the inferior aspect of the labia majora, in the posterior introitus, and is crossed by the labium minus. Duct cysts and gland cysts are indistinguishable, and the terms are used interchangeably. A Bartholin duct abscess may be primary (from bartholinitis) or secondary (from infection of Bartholin cyst). (Pundir & Auld, 2016)

Plan/Therapeutics

Plan: 

· Treatment can be conservative or surgical, and the choice depends on symptoms, age of the patient, and whether infection is present. (Pundir & Auld, 2016)

· amoxicillin/clavulanate: 875 mg orally twice daily for 7 days together with clindamycin: 300 mg orally four times daily for 7 days. (Pundir & Auld, 2016)

· Sitz baths or warm compresses to aid drainage. (Scott, 2013)

· If therapy doesn’t work after 7 days, refer member to surgeon because over age 40 years, the possibility of malignancy must be considered, and biopsy may be indicated, but simple asymptomatic cysts can be managed in the same way once malignancy has been excluded. (Pundir & Auld, 2016)

 Evaluation of patient encounter:

This encounter allows me the opportunity to review the differential diagnoses and final diagnosis related to A Bartholin duct cyst. I was educated on A Bartholin duct cyst treatment and the importance a close follow up in member of 40 years old and older. The importance establishes an open communication with our clients. After this encounter I was able to verbalize understanding of the treatment plan for this condition.