Soap note

Name: MR

Date: 04/26/2019

Age: 55

Sex: Female

SUBJECTIVE

CC: 

“I’m very concerned about my vaginal bleeding and the abdominal pain is not resolving”

HPI: 

A 55-year-old Hispanic patient presents to the clinic complaining about profuse post-coital vaginal bleeding. She has not had irregular bleeding previously and she stays that her monthly menses are usually regular. The patient reports that for several months, she has been experiencing vague lower abdominal pain. Upon further questioning, she also states that she occasionally has foul smelling, blood stained vaginal discharge. MR is unsure of her partner’s sexual activity and they do not use condoms when having sex. She additionally attests that since ten years ago, she has not received gynecological care.

Medications:

Enalapril 20 mg PO daily – For managing hypertension

Atorvastatin 20 mg PO at night– Hyperlipidemia  

PMH

Allergies: NKDA 

Medication Intolerances: No recorded

Chronic Illnesses/Major traumas: Hyperlipidemia × 4 years, HTN × 5 years

Hospitalizations/Surgeries: N/A

Family History

Parents alive. Mother was diagnosed at age 60 with breast cancer and Father has COPD, HTA and Hyperlipidemia.

Social History

Patient currently works as a cashier in a local fashion retail store. She is a 25-pack year cigarette smoker and admits to drinking alcohol occasionally. She denies using marijuana, cocaine, or other illicit substances

ROS

General

Denies fever, weight loss, fatigue, or weakness.

Cardiovascular

Does not have chest pain, palpitations, edema and, dyspnea.

Skin

Denies rashes, bruising, delayed healing, bleeding, or any mole/lesion changes

Respiratory

 Denies any SOB, cough or sputum.

Eyes

Does not wear reading glasses, she denies diplopia or eye pain

Gastrointestinal

Patient affirm lower abdominal pain and intermittent cramping. She states that these symptoms have been present for several months now. Denies heartburn or abdominal discomfort. Denies nausea, vomiting or diarrhea.

Ears

Patient reports that her hearing is intact with no notable changes in the recent past

Genitourinary/Gynecological

Patient refers plenty post-coital vaginal bleeding. On several occasions, she has noticed a foul smelling, blood stained vaginal discharge. Patient is G3, P3. Pt is not sure about her last Pap. She does not receive regular gynecologic care or attend routine checkups since 10 years ago.

Nose/Mouth/Throat

Denies nasal congestion and other sinus problems. No oral lesions or dental problems. She also denies throat pain

Musculoskeletal

Denies muscle pain, joint pain, or stiffness

Breast

Deny tender or mass.

Neurological

Deny nervousness, anxiety or irritability.

Heme/Lymph/Endo

WNL

Psychiatric

Denies history of mental conditions. She also denies suicide ideation

OBJECTIVE

Weight: 139 lbs   BMI: 24.7

Temp:98.6 F

BP: 126/65 mmHg

Height: 5’4’’

Pulse: 76 beats/min

Resp: 17 breaths/min

General Appearance

Healthy-appearing ,well-nourished Caucasian female who is alert and in no apparent distress

Skin

Skin is warm and dry

HEENT

PERRLA; Extra ocular motions full. Conjunctiva clear. Gross visual fields full to confrontation. TM landmarks well visualized. Neck supple with no masses. No nasal discharge or obstruction.

Cardiovascular

Normal S1 and S2; PMI at the 6th ICS; RRR with no MRG; No thrills or heaves

Respiratory

CTA bilaterally

Gastrointestinal

The abdomen is soft with no enlargement Minimal tenderness across lower abdomen, tenderness greater on left than right side, without guarding or rebound.

Breast

Medium sized breasts, nipples symmetrical without discharge. No masses, lesions, or retraction appreciated on exam. (-) lymphadenopathy bilaterally in axillary region

Genitourinary

External genitalia unremarkable. Speculum examination – reveals large traces of blood noticed in the vaginal vault. Cervix replaced by a 7 cm , friable cervical mass deviated to the right Bimanual examination – reveals 6 cm fixed mass that obliterates left vaginal fornix, no extension to the vagina.

Musculoskeletal

Full ROM. No deformities, cyanosis, edema, or varicosities

Neurological

AAO × 3, pleasant affect. No motor/sensory/perceptual deficits

Psychiatric

A & O × 3. Rate of thoughts logical and normal. Judgment intact. Patient appears content/happy, cooperative, calm, and pleasant.

Lab Tests

Speculum examination – reveals large traces of blood noticed in the vaginal vault. Cervix replaced by a 6 cm , friable cervical mass deviated to the right.

Bimanual examination – reveals 7 cm fixed mass deviating to the left, which obliterates the vaginal fornix, no extension to the vagina.

Thin prep Pap smear – Results abnormal

Urinalysis – Pending results

HPV Test – Positive for HPV 16 and 18

Colposcopy – Abnormal

Special Tests

Cervical Biopsy – Pending

 Diagnosis

Include at least three differential diagnosis

D25.9 Leiomyoma of uterus, unspecified

O86.11 Cervicitis

C54.1 Malignant neoplasm of endometrium.

N84.1 Polyp of cervix uteri

Final diagnosis

C53.9 Malignant neoplasm of cervix uteri, unspecified (Both subjective and objective findings support this definitive diagnosis. Symptoms such as heavy post-coital vaginal bleeding, blood stained vaginal discharge, abdominal pain, as well as positive findings of fungating, friable cervical mass, positive HPV 16 and 18, and abnormal Pap and colposcopy all suggestive of cervix cancer).

PLAN including education

Plan: 

· Further testing

The practitioner ordered an MRI scanning for radiological scanning. According to clinical guidelines by the Scottish Intercollegiate Guidelines Network (2008), consistent evidence exists suggesting that MRI is more accurate as compared to CT for radiological staging of cervical carcinoma, with staging accuracies ranging from 78-97%. The clinical guidelines also affirm that “thin section axial and sagittal T2 sequences including axial oblique sections perpendicular to the long axis of the cervix, are of most value in primary tumor assessment” (p. 8). Apart from primary tumor assessment, MRI is also superior to other imaging studies in in assessments of vaginal invasion, bladder and rectal invasion, metastatic lymphadenopathy, and parametrial staging. Findings from this testing revealed that the patient had Stage IIA2 cervical cancer.

· Medication

The recommended treatment approach for this patient with Stage IIA2 cervical cancer was initiating chemotherapy using cisplatin 50 mg/m2 on day 1 plus paclitaxel 135 mg/m2 every 3 weeks. Guidelines from the Scottish Intercollegiate Guidelines Network (2008) indicate that despite low response rates, cisplatin remains the standard chemotherapy because of its effects on overall survival and time to progression. The combination therapy of cisplatin plus paclitaxel also improves the overall quality of life in patients with cervical cancer (CDC, 2017). In order to guarantee the success of this therapy, practitioners must ensure that they prescribe, administer, dispense, and supervise in an effective and safe manner in accordance with established clinical guidelines such as those advocated by the Joint Collegiate Council for Oncology.

· Education

The patient was educated about the signs and symptoms that she should monitor for complications associated with cervical cancer. Palmer & Gillespie (2010) contend that such warning signs include active bleeding, increased pus-like discharge, serious cramping, fever, and intense abdominal pain. Patient notified to return immediately to the ED if she notices a flare-up of these warning signs. DT also notified about some self-care practices that could help her in managing her cervical cancer. The clinician additionally informed the patient about potential cervical cancer risk factors that she should strive to modify. Recognized risk factors for developing this malignancy include cigarette smoking, HPV infection, and socioeconomic status (Schwinghammer & Koehler, 2014). Furthermore, the clinician provided sex education to the patient, as women with cervical cancer often suffer from sexual problems including loss of libido and decreased orgasm.

· Nonmedication treatments

An effective Nonmedication treatment for cancer of the cervix is radical hysterectomy (RH). This surgical procedure involves the en-bloc removal of the cervix, uterus, upper vagina, and parametrial tissues (Scottish Intercollegiate Guidelines Network, 2008). Nevertheless, in order to minimize post-surgical morbidity when after performing RH, it is paramount for practitioners to correctly and accurately assess the size of primary tumor radiologically and ensure that there is no pelvic lymphadenopathy. Hormone replacement therapy (HRT) is also an effective no pharmacological intervention for patients with cervical cancer, particularly those with absent ovarian function following radiotherapy and/or chemotherapy. Schwinghammer & Koehler (2014) reiterate that HRT significantly reduces post-menopausal symptoms as well as long-term post-radiation vaginal, bladder, and rectal complications.

· Follow-up

Patient notified about regular follow-ups at 6 months’ intervals, or should the symptoms worsen or fail after beginning the chemotherapy treatment.