Hi I need a response for the 2 below soap notes

Peer 1

 

Patient name: D, V  Age: 40  Gender: Female

Chief Complaint:” I have been without menses for 2 months”

HPI: Patient 40 years old female, Hispanic, comes to visit for gynecologic examination, complaining of amenorrhea for 2 months, reports irregular periods before.

Past Medical Hx:

 Essential (primary) hypertension I10

Obesity, unspecified E66.9

Hyperlipidemia E78.1 

Type 1 Diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.319

Pap smear 

 Date: 11/17/2018; Notes: HPV negative but reactive cellular changes and/or repair are present, the predominance of coccobacilli consistent with a shift in vaginal flora is present 

 Date: 11/23/2016; Notes: Normal 

 Notes: Normal 2008 Negative for Cancer of the ovaries; Asthma; Cancer of the breast; Cancer of the lung; Diabetes; Heart failure, systolic; Heart disease (CAD); Cancer of the colon; Heart failure, diastolic.

Menstrual History 

Menstrual information 

 Notes: Irregular 

Pregnancy History 

Past pregnancy 

 Notes: G2 P2 A0 L2

Surgical History 

Cesarean section 

Social History 

Sexually active 

Sexually active 

Employed 

Children 

Married 

Never smoked 

Negative for: Exercise; Past drug use; Alcohol use 

 Family Hx: 

Father: Diabetes mellitus

Mother: Hypertension,

Grandparents: Diabetes mellitus

Allergies: No Know Allergies

Current Medication:

 Lisinopril 10 mg tab PO daily.

Glargine 40 units at bedtime

Atorvastatin 80 mg tab PO at bedtime daily

Review of systems

General/Constitutional 

Patient t Reports: Amenorrhea for 2 months, she denies chills and night sweats. She also denies weight loss and weight gain or fever.

HEENT

Eyes: Denies swellings, itchiness, blurry vision, discharges. The patient wears glasses.

Head: Denies (pain, vertigo, tinnitus, hoarseness, dysphagia, cough, throat pain, hearing problems, trauma, lump).

Systemic symptoms: Denies (fever, chills). No recently weight loss.  

Neurological: Denies sleeping problems, nausea, vomiting, vertigo, weakness, gait change, dizziness, or headache.

Respiratory: Denies cough, shortness of breath, chest pain, cyanosis. 

Cardiovascular: Last EKG (atrial fibrillation). The patient denies chest pain, dizziness, SOB, weakness, fatigue, bilateral lower extremity swelling.

Gastrointestinal: Denies abdominal pain, distention, anorexia, diarrheas, nauseas, vomiting, flatulence.

Genitourinary: Pt Reports: Amenorrhea for 2 month, She denies increased urinary frequency, blood in the urine, and nocturia.

Endocrinology: Denies: Excessive appetite; Excessive sweating; Excessive thirst; Excessive urination; Heat/cold intolerance; Hair loss; Excess hair growth

Musculoskeletal: Denies arthralgia, myalgia, or pain to the movement of the joints or muscles cramp.

Integumentary: Denies discomfort and itching in her vagina, denies swollen.

Pt Denies: Skin lump/mass; Mole changes; Performs monthly self-breast exam; Breast lump/mass; Breast pain; Nipple discharge; Stretch marks; Varicose veins; Phlebitis 

Neurological: Pt denies Headaches Pt Denies Numbness/tingling; Seizures; Tremors; Difficulty walking; Localized weakness Psychiatric. Pt Denies: Anxiety; Depression; Frequent crying; Nervousness; Hallucinations; Memory loss; Sleep problems; Suicidal thoughts 

Hematologic/Lymphatic Pt Denies: Easy bleeding or bruising; Anemia; Swollen glands Allergic/Immunologic 

Physical examination

Weight: 172 lbs     Temp 98.1 F BP: 132/86 Height 5’2” Pulse:82 Resp: 20

General: The patient is alert and oriented, able to provide accurate information, good eye contact during the interview, cooperative. The patient states a good understanding of the conversation. The patient seems slightly distressed

HEEET Head: Normocephalic, atraumatic, symmetric, no visible or palpable masses, depressions, or scaring. Good hair distribution, good hygiene. No bleeding, no papules, no vesicles. 

Neck: Trachea in the midline, No neck veins distention. No posterior cervical adenopathy. No carotid bruits and no goiter.

Ears: TMs (Pale, gray, translucent appearance, Cone of light and bony landmarks visible) & mobile, hearing intact. Ear canals clear without inflammation or redness.

Nose: Smell sense intact, No external or internal lesions observed. No exudate or secretion. No observed septum deviation.

Eyes: Visual acuity intact 20/20 with corrective glasses, Eyes symmetric, no blepharitis, no redness clear conjunctiva, no ocular discharge bilaterally. PERRLA

Throat: Gap reflex present, uvula in the midline, Good hygiene, No lesions in soft tissues, no gingival inflammation, no bleeding. Tonsils 2+

Respiratory: Chest symmetric, Tactile fremitus present. thoracic expansion symmetric. No wheezing or crackles sounds.

Breast: No overlying skin changes; No dimpling; No nipple retraction; No masses or lumps; Right breast no palpable masses or lumps; Left breast no palpable masses or lumps; No tenderness; No regional lymphadenopathy

 Additional comments: US-guided biopsy right breast, showing fibroadenoma, no malignancy was seen. Diagnostic mammogram and ultrasound in 1 year are recommended (August 2021) 

Skin: Warm to touch, no hyperthermia, Inguinal intertrigo

Cardiovascular: HR regular. No murmur, no thrill, no rubs, No swollen leg. All pulse palpable, no sign of DVT or PAD.

 Abdomen: Flat, no tender no distended, No scar visible on inspections, soft on palpation. Liver palpable no splenomegaly, no masses, no pain with palpation. Bowel sound present in all quadrant. The patient denies Costovertebral angle tenderness.

Genitourinary: No erythema, masses, or lesions detected on the external genitalia. The vaginal mucosa is pink. No blood detected on the stool, which is brown. No inguinal adenopathy or adnexal masses noted. No rectovaginal masses detected. Vulva,Vagina,Cervix (Normal appearance); By TV sonogram (Uterus normal size/shape with normal ovaries) 

Lymphatic: No visible or palpable adenopathy.

Extremities: Full range of motion in 4 extremities, Pulses present and symmetric. No swelling, no deformities 

Neurological: All cranial nerves intact. No weakness, no vertigo, or dizziness. Adequate sensation in 4 extremities. Reflexes are +2 

Assessment and Plan

Diagnosis: 

Amenorrhea, unspecified N91. Amenorrhea is the absence of menstruation. Secondary amenorrhea occurs when you’ve had at least one menstrual period and you stop menstruating for three months or longer. Secondary amenorrhea is different from primary amenorrhea. It usually occurs if you haven’t had your first menstrual period by age 16.A variety of factors can contribute to this condition, including birth control use, certain medications that treat cancer, psychosis, or schizophrenia, hormone shots, medical conditions such as hypothyroidism, being overweight or underweight

Differential Diagnosis:

Hypothyroidism E03.9: Other clinical signs of thyroid disease are usually noted before amenorrhea presents. Mild hypothyroidism is more often associated with hypermenorrhea or oligomenorrhea than with amenorrhea. Treatment of hypothyroidism should restore menses, but this may take several months.

HYPERGONADOTROPIC HYPOGONADISM E23.0: Ovarian failure can cause menopause or can occur prematurely. On average, menopause occurs at 50 years of age and is caused by ovarian follicle depletion. Premature ovarian failure is characterized by amenorrhea, hypoestrogenism, and increased gonadotropin levels occurring before 40 years of age and is not always irreversible (0.1 percent of women are affected by 30 years of age and one percent by 40 years of age). Approximately 50 percent of women with premature ovarian failure have intermittent ovarian functioning with a 5 to 10 percent chance of achieving natural conception

Polycystic ovary syndrome (PCOS) E 28.2: is a hormonal disorder common among women of reproductive age. Women with PCOS may have infrequent or prolonged menstrual periods or excess male hormone (androgen) levels. The ovaries may develop numerous small collections of fluid (follicles) and fail to regularly release eggs.

The exact cause of PCOS is unknown. Early diagnosis and treatment along with weight loss may reduce the risk of long-term complications such as type 2 diabetes and heart disease.

 PLAN

Further Testing:

 Pregnancy test. This will probably be the first test your doctor suggests, to rule out or confirm a possible pregnancy.

Thyroid function test. Measuring the amount of thyroid-stimulating hormone (TSH) in your blood can determine if your thyroid is working properly.

Ovary function test. Measuring the amount of follicle-stimulating hormone (FSH) in your blood can determine if your ovaries are working properly.

Prolactin test. Low levels of the hormone prolactin may be a sign of a pituitary gland tumor.

Transvaginal ultrasound.

Medication: Treatment depends on the underlying cause of your amenorrhea. In some cases, contraceptive pills or other hormone therapies can restart your menstrual cycles. Amenorrhea caused by thyroid or pituitary disorders may be treated with medications. If a tumor or structural blockage is causing the problem, surgery may be necessary.

Education: Some lifestyle factors such as too much exercise or too little food can cause amenorrhea, so strive for balance in work, recreation, and rest. Assess areas of stress and conflict in your life. If you cannot decrease stress on your own, ask for help from family, friends or your doctor.

Be aware of changes in your menstrual cycle and check with your doctor if you have concerns. Keep a record of when your periods occur. Note the date your period starts, how long it lasts and any troublesome symptoms you experience.

Return to office: The patient should return to the clinic immediately if the condition worsens and symptoms persist. Follow-up should be done in two weeks if the condition does not worsen.

References 

DeCherney AH, et al. Current Diagnosis & Treatment Obstetrics & Gynecology.11th ed. New York, N.Y.: The McGraw-Hill Companies; 2013. http://www.accessmedicine.com/resourceTOC.aspx?resourceID=788. Accessed Jan. 21, 2014.

Klein DA, et al. Amenorrhea: An approach to diagnosis and management. American Family Physician. 2013;87:781.

Goldman L, et al. Goldman’s Cecil Medicine. 24th ed. Philadelphia, Pa.: Saunders Elsevier; 2012. http://www.clinicalkey.com. Accessed Jan. 20, 2014.

Reply

Patient Information:

Name: KG

Age: 23 y/o.

Gender: Female.

Race: Hispanic

Advanced Directives:  Full Code 

Source: Patient        

Past medical History

Chronic Illnesses/Major traumas: Obesity.

Family Medical History: Mother diagnosed with: Diabetes Mellitus Type 2, 45 y/o, alive.

Father diagnosed with: Gout, 50 y/o, alive.

Allergies: None.

Surgery: None

Screening Hx/Immunizations Hx: TT, 2020. Flu: 2020, Pap smear 2020 (Negative)

Current Medications: 

-Tylenol 500 mg 1tab PO every 6 hours for mild pain/fever

Social history: Patient has high school degree, and she works at a mall for 5 years. She is single and she is sexually active and has history of unprotected vaginal sex with multiple partners. Actually, she lives with her son and her parents, he is 5 years old. The support is her family and denies any needs at this time. She has adequate shelter. She has a sedentary life. She doesn’t have healthy diet. She denies substance abuse, ETOH, tobacco, marijuana or illicit drug ingestion.

Subjective:

CC: “I had been with foul-smelling vaginal discharged, pain during urination and bleeding after having sex for the last 2 weeks without relief.”

HPI: This is a 23-yr. old Hispanic, female who goes to the clinic with c/o foul-smelling vaginal discharged, dysuria, dyspareunia and bleeding after coitus for the last 2 weeks without relief. Patient denied fever or previous vaginal malodorous. She is sexually active and reports multiple sexual partners, a history of negative result of Papanicolaou tests in the recent past, and recent unprotected vaginal intercourse. She claims poor pain relief with Tylenol 500 mg oral every 6 hours. Also, she denies history of sexually transmitted disease, douching and antibiotic use recently. She informs the vaginal discharge looks like creamy greenish and has foul-smelling odor. She mentions that she feels a sharp pain in the lower abdomen which she rates a 3 out of 10. She refers mild distress related to painful sexual intercourse. Denies abdominal trauma, fatigue, vomit, nausea and diarrhea. She does not present any past medical history. She has not had similar symptoms in the past. The menarche was at 12 y/o, the LMP: 10/5/2020 for 6 days, regular cycle, plus the spots already described, G1T1P1A0L1.

ROS:

General: She refers weight gain 10 pounds in the last month, denies fatigue, fever, malaise and decreased energy level. 

Skin: She denies healing problems, rashes, bruising, bleeding or skin discolorations, no changes in lesions. She has a mole (birthmark) in her left side of her neck. 

Eyes: She denies changes in her vision, diplopia, blurry vision, no redness or swelling, watering or discharge.

Ears: She denies hearing loss, ear pain, ringing in ears, discharge.

Nose/Mouth/Throat: She denies runny nose, epistaxis, hoarseness, dysphagia, sinus problems, or discharge, no dental disease, and no throat pain.

Breast: Refers to do SBE every month, denies lumps, bumps or changes.

Heme/Lymph/Endo: She denies bruising or bleeding, purpura, petechiae, prolonged or excessive bleeding, no blood transfusion and HIV Hx, night sweats, swollen glands, no increase thirst, increase hunger, cold or heat intolerance.

Cardiovascular: She denies palpitations, orthopnea, chest pain, and no edema.

Respiratory: She denies cough, wheezing, and dyspnea at this moment.

Gastrointestinal: She denies nausea, vomiting, diarrhea, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools, and no abdominal pain. Denies colonoscopy.

Genitourinary/Gynecological: She complains of creamy greenish vaginal discharge accompanied with dyspareunia, and vulvar burning, especially when she urinates, sharp pain in the lower abdomen which she rates a 3 out of 10, 4 days ago. The menarche was at 12 y/o, the LMP: 10/5/2020 for 6 days, regular cycle, plus the spots already described, G1T1P0A0L1. Last Pap smear at 2020 was negative.

Musculoskeletal: She denies any limitation in movements in upper or lower extremities. No other joint pain, stiffness, swelling, or muscle plain.

Neurological: She denies seizures, transient paralysis, weakness, black out spells, and no syncope. She refers paresthesia in bilateral lower extremities.

Psychiatric: She denies any changes of behavior, depression, sleeping difficulties, suicidal ideation/attempts. She refers mild distress related to painful sexual intercourse.

Objective:

Physical Exam:

GENERAL: Patient is obese, no acute distress, maintain adequate hygiene. Patient is alert and oriented and answers questions appropriately. She is very cooperative and maintain good eyes contact.

Vital signs:

Temperature: 97.5 F

RR: 18 x min

HR: 73 x min

O2Sat: 98 %; 

Blood Pressure: 130/75 mmhg

BMI: 32.9

Weight: 180 pounds. Height: 5.2”.

Pain scale: 3/10.

Skin: The skin is white, warm, dry, clean, pink, and intact. No noted rashes, no open wounds. Noted a mole 1/3 superior of left side of the back, light brown, irregular shape, flat, 7 inches, not painful, not itching, no changes in color.

HEENT

Head: Normocephalic, no deformities and midline.  Hair is clean, thick, soft, and curly and well distributed on the head. Scalp is clean, dry, and without lesions. 

Eyes:  Symmetrical, pupils’ equal round and reactive to light and accommodation, red reflex noted and light reflected symmetrically bilaterally, visual field full by accommodation. No conjunctival or scleral injection. She wears corrective lenses.

Ears: TM is pearly gray and translucent, bony landmarks, and light reflex noted bilaterally. Canals patent. No lesion noted.

Nose: External nose is smooth and symmetrical, firm/stable structure noted, mucosa/turbinates deep pink, moist, glistening. No septal deviation.

Throat: Posterior pharyngeal wall is moist, glistening, non/reddened, without exudate, Tonsils are 1+, bilaterally.

Neck: Symmetric. Noted 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

Heart: Upon auscultation S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs nor murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

Chest: Symmetric. Lungs are clear bilaterally anterior/posterior, no wheezing, no rhonchi, no adventitious breath sounds.

Gastrointestinal: Abdomen flat, no deformities; BS active in all 4 quadrants, mild diffuse lower abdominal tenderness on deep palpation. No hepatosplenomegaly. 

Breast: No tender, no deformities, no lumps or mases noted.

Genitourinary: Bladder is non-distended; no CVA tenderness.

External genitalia reveal coarse pubic hair is well distribution; skin color is consistent with general pigmentation. Noted an erythematous area in the upper third of the vulva, near the urethra. Well estrogenized. A small speculum was inserted; vaginal walls are covered by purulent exudate and bleeding. Upon detaching them from the base, an erythematous area is left. Cervix is erythematous with punctate hemorrhages (strawberry-patch cervix), also friability noted and multiparous. Scant purulent and cloudy drainage present. On bimanual exam, cervix is firm, cervical motion tenderness is also present.  Uterus is normal size, minimally tender, antevert and positioned behind a slightly distended bladder. Rectovaginal exam reveals uterosacral nodularity and exquisite tenderness. Stool is soft, brown and heme-negative. Ovaries are nonpalpable.

Heme/Lymph/Endo: Upon palpation no lymphadenopathy and organomegaly noted.

Musculoskeletal: Symmetric, full ROM in all extremities. Extremities are warm without edema.

Neurological: Patient is A, A, OX 4. Speech clear, maintain good tone. Posture is erect. The balance is stable and the gait is rhythmical, flowing, effortless, with freely swinging legs and with an upright body posture. 

Psychiatric: She is alert and oriented X 4. She is dressed in a clean dress and coat. She maintains eye contact. Her speech is soft, and clear, answers questions appropriately.

Lab Tests

•           NAAT: It is positive for Chlamydia trachomatis or Neisseria gonorrhoeae: Still pending the result.

•           Urine culture and sensitivity: Still pending the result.

•           Wet mount examination of cervical discharge:  Sensitive indicator of cervical inflammation, in the absence of inflammatory vaginitis. Microscopy is only 50% sensitive for detection of Trichomonas vaginalis, whereas culture is the most sensitive test. Bacterial vaginosis may be diagnosed by presence of at least 3 of the 4 Amsel criteria: 1) adherent white vaginal discharge; 2) clue cells on microscopy (vaginal epithelial cells with distinctive stippled appearance as covered by bacteria); 3) vaginal pH >4.5; 4) “whiff test” (release of fishy odor following addition of 10% potassium hydroxide solution). Result shows>10 WBCs per high-power field of vaginal fluid (leukorrhea), trichomonads, clue cells, pH: 5, fishy amine odor with application of 10% KOH.

•           HIV test: Negative. 

•           Rapid tests (OSOM Trichomonas, AFFIRM VPIII): Fast and reliable point of care tests with sensitivity >83%, specificity >97%. Results available within 10 minutes for OSOM Trichomonas rapid test and in 45 minutes for AFFIRM VP III. Result is positive for Trichomonas vaginalis

•           Gram stain of cervical discharge: For diagnosis of bacterial vaginosis. Nugent score is used, which involves counting bacterial morphocytes. Possible result reveals Lactobacillus morphotype reduced or absent. Still pending the result.

•           Thayer-Martin agar cervical culture: For detection of N gonorrhoeae. Possible result reveals growth of pathogen. Still pending the result.

•           Pregnancy test: It is important to determine if patient is not pregnant to provide her the appropriate treatment, avoid the teratogenesis (Jameson et al., 2020). It was negative.

Special Tests: None

Primary Diagnosis

            A: The primary diagnosis for the patient is: Cervicitis (N72): Cervicitis is common and often asymptomatic, but if left undiagnosed or untreated can result in pelvic inflammatory disease, which can lead to substantial long-term ill effects such as infertility and chronic pelvic pain. Implementing screening protocols for high-risk populations may reduce adverse outcomes from cervicitis. Screening for other sexually transmitted infections (STIs) should be offered concomitantly. While Neisseria gonorrhoeae and Chlamydia trachomatis are the most commonly isolated organisms, in most cases no organism is identified. Clinical suspicion is generally sufficient to justify therapy, but of the diagnostic aids, nucleic acid amplification testing remains the most sensitive and specific tool for accurately diagnosing N gonorrhoeae and C trachomatis. If the presentation suggests cervicitis, and the patient is deemed at high risk for STI, patients are empirically treated with a regimen targeting STIs. There are some risk factors to develop the disease such as women of reproductive age (15 to 29 years old), prior history of STI, inconsistent condom uses and multiple sexual relationships (Jameson et al., 2020).

      In this patient, we can find some signs and symptoms such as: her c/o foul-smelling vaginal discharged, dysuria, dyspareunia and bleeding after coitus for the last 3 weeks without relief. Patient denied fever or previous vaginal malodorous. She is sexually active and reports multiple sexual partners, a history of negative result of Papanicolaou tests in the recent past, and recent unprotected vaginal intercourse. She claims poor pain relief with Tylenol 500 mg oral every 6 hours. Also, she denies history of sexually transmitted disease, douching and antibiotic use recently. She informs the vaginal discharge looks like creamy greenish and has foul-smelling odor. She mentions that she feels a sharp pain in the lower abdomen which she rates a 3 out of 10. She refers mild distress related to painful sexual intercourse. Also, physical examination reveals vaginal walls are covered by purulent exudate and bleeding. Upon detaching them from the base, an erythematous area is left. Cervix is erythematous with punctate hemorrhages (strawberry-patch cervix), also friability noted and multiparous. Scant purulent and cloudy purulent and cloudy drainage present. 

            On bimanual exam, cervix is firm, cervical motion tenderness is also present.  The patient presents some risk factors to develop the disease such as women of reproductive age (15 to 29 years old), multiple sexual relationships and inconsistent condom uses.

Secondary Diagnosis:

• Obesity (E66.9): Patient has BMI 32.9.
• Melanocytic nevi of trunk (D22.5): Upon physical exam noted a mole 1/3 superior of left side of the back, light brown, irregular shape, flat, 7 inches, not painful, not itching, no changes in color.

Secondary Diagnosis:

• Obesity (E66.9): Patient hasBMI32.9.
• Melanocytic nevi of trunk (D22.5): Upon physical exam noted a mole 1/3 superior of left side of the back, light brown, irregular shape, flat, 7 inches, not painful, not itching, no changes in color.

Differential Diagnoses

• Cervical dysplasia(N87.9):Patient may report a history of abnormal Pap smears. Pap smear reveals abnormal cervical cytology. Colposcopy shows acetowhite epithelium, abnormal vascular patterns (punctations, mosaicism), gross lesion. Cervical biopsy reveals cervical intraepithelial neoplasia (Rhoads et al.,2018).
• Cervical cancer(C53.9):Patient may report a history of abnormal Pap smears. May present with heavy or irregular intermenstrual vaginal bleeding along with abnormal vaginal discharge. Pap smear reveals abnormal cervical cytology. Colposcopy shows abnormal vascularity, white change with acetic acid, or obvious exophytic lesions. Cervical biopsy reveals confirms diagnosis histologically and identifies subtype (Rhoads et al.,2018).
• Pelvic inflammatory disease (N73.9):Patient presents with abdominal pain and tenderness, pelvic pain and cervical tenderness, fever, nausea/anorexia. Clinical exam of cervical motion tenderness and abdominal tenderness, as well as sign of fever or leukocytosis, can be used to diagnose this condition. Patients with Chlamydia trachomatis cervicitis, if left untreated, carry a 40% risk of developing PID. Transvaginal ultrasound shows classic signs are tubal wall thickness greater than 5 mm, incomplete septae within the tube, fluid in the cul-de-sac, and a cogwheel appearance on the cross-section of the tubal view; may also see tubo-ovarian abscess; may be normal (Rhoads et al.,2018).

PLAN:

• It is recommended for nonpregnant women with confirmed trichomoniasis infection the treatment with metronidazole. Metronidazole and tinidazole are the only known effective drugs for the treatment of trichomoniasis, with up to 95% success rates. Consider rescreening at 3 months (Jameson et al., 2020).

Med/Meds:

• metronidazole: 500 mg orally twice daily for 7 days

Symptomatic treatment: 

• ibuprofen: 400-600 mg orally every 4-6 hours when required, maximum 2400 mg/day, for mild pain/fever.

Treatments:

• For external dysuria may also be alleviated by urinating with the genitals submerged in water.

Diagnostic:

•           NAAT

•           Urine culture and sensitivity

•           Wet mount examination of cervical discharge 

•           HIV test

•           Rapid tests (OSOM Trichomonas, AFFIRM VPIII

•           Gram stain of cervical discharge

•           Thayer-Martin agar cervical culture

•           Pregnancy test

Procedures performed: None

Education:  Patient was instructed to:

•           Promote the monogamy (or at least a reduction in the number of partners)

•           Encourage the use of male condoms may help prevent spread of infection.

•           Educate about the importance of completing the treatment and side effects of medication.

•           Encourage follow up diagnostic test to obtain an accurate and effective treatment.

•           Abstain from sex until the symptoms completely heal. 

•           Advised her sexual partners to go to a clinic for evaluation as there are high chances that they are infected too. 

•           Observe hygiene and sanitation to ensure that the symptoms such as irritation and swelling improve.

•           Advised for external dysuria may also be alleviated by urinating with the genitals submerged in water. 

•           Encourage that if these symptoms do not improve in the next week of treatment, for her to come back to the clinic for more evaluation. 

•           Avoid use of fabric softeners, harsh soap, nylon or synthetic underwear.

•           Encourage the importance to maintain hand hygiene, diet habits and lifestyle modification such as increase physical activity. 

•           Educate about 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 (Burns et al., 2017). 

Referrals: None

Follow-up:  Pt is advised to follow-up in 7 days.  If symptoms persist or worsen call or make an appt.  Questions were answered to patient’s satisfaction.

Peer 2

 

DEMOGRAPHIC INFORMATION

Name: Mrs. M.E.

Age: 47-year-old

Race: Hispanic.

Insurance: Medicaid.

Advance directives: yes, since 04/25/2020.

Subjective Data:

CHIEF COMPLAIN: “I have been having hot flashes for the past few months”.

HISTORY OF PRESENT ILLNESS: Mrs. ME is 47 y/o female, Hispanic, she states in our office today because she has been having hot flashes for the past few months. Patient reports experiencing two or three hot flashes per day. Mrs. ME also reports she is awakened from sleep, soaked by night sweats. Her symptoms began seven months ago, and over that time, they have worsened to the point where have become very bothersome. She is worried because she cannot remember the date of her las period; but she’s sure she does not see her period several months ago. Patient denies headache, fever, change in appetite or weight.

PAST MEDICAL HISTORY: Denies past medical history

SURGICAL PROCEDURES: T and A as a child

OB/GYN HISTORY: G1 T1 P0 A0 L1

HOME MEDICATIONS: Centrum Women PO Daily Vitamin C (500mg) PO Daily ALLERGIES: NKA VACINATIONS: Immunizations are up to date

PREVIOUS SCREENING TEST RESULT: Normal pap smear in March 2017

Normal Mammography in July 2016

FAMILY HISTORY: Mother: Alive, Rheumatoid arthritis Father: Alive, Hypertension, Obesity

SOCIAL HISTORY: Home/Environment: Live with her husband. Nutrition/ Health: Normal weight Violence or abuse in the home: No Marital Status: Married Sexual Status: Active

SOCHX: Denies alcohol or drug use. Smoker. Uber driver. Sedentary life.

REVIEW OF SYSTEMS: 

CONSTITUTIONAL SYMPTOMS: Patient reports experiencing two or three hot flashes per day. Mrs. ME also reports she is awakened from sleep, soaked by night sweats. Denies headache, fatigue, fever or chills. Denies weight gain or weight loss.

HEENT: Head: Denies head injury or change in LOC. Denies diplopia or blurred vision. Denies red eyes or itching. Denies nasal congestion or sneezing. Denies ears pain, fullness, itching, and loss of hearing or drainage. Throat: Denies sore throat, loss of tastes or difficulty swallowing. Denies hoarseness or bleeding gums. Neck: Denies pain, lesion, bruits or masses.

BREAST: No pain, no lump, no nipple discharge.

RESPIRATORY: Denies cough, chest pain or shortness of breath. CARDIOVASCULAR: Denies chest pain, palpitations, dizziness or fatigue

GI: Denies diarrhea, nausea, vomiting, fever, chills or abdominal pain.

GU: Patient cannot remember the date of her las period. Had first period at age 10. Denies dysuria, polyuria, burning, frequency, offensive odor of urine, incomplete bladder emptying, or back/flank pain.

MUSCULOSKELETAL: Denies falls. Denies ambulating, squatting or bending down pain, Denies joint pain. Denies noticing lengthening of the extremity.

NEUROLOGICAL: Denies changes in LOC. Denies memory loss or imbalance. Denies history of tremors or seizures.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINE: No reports of sweating, cold or heat intolerance.

HEMATOLOGIC/LYMPHATIC: No enlarged nodes. No history of splenectomy.

OBJECTIVE:

T: 98.9◦F HR: 75 (Peripheral) RR: 17 BP: 120/70 SpO2: 98% HT: 5.4’ WT: 135 lb BMI: 22.75 (Normal weight)

GENERAL APPEARANCE: 

Well-nourished, normal habitus. Gait is normal, posture is normal.

HEENT: Head normocephalic without evidence of masses, trauma, depressions or scaring.

Eyes: Visual acuity intact, normal conjunctiva, EOM intact, PERRLA. Fundoscopic exam: Normal optic discs and vessels, no exudate or hemorrhage. Ear canal without redness or irritation, TMs clear, pearly, bony landmarks visible. No discharge, no pain noted. Nose: No external lesions, appearance of nose normal without mucous, nares patent, septum normal. Mouth: Mucous membranes moist, no mucosal lesions. Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation, Pharynx: Mucosa moist, no mucosal lesion. 4 ulcers or masses present.

Neck: Supple, negative for lesion, bruits, masses or adenopathy. No thyromegaly. No JVD distention. BREAST: Normal size for female, normal shape, symmetrical, no dimpling, denies tenderness. RESPIRATORY: Clear to auscultation, without crackles, wheezes or rhonchi.

CARDIOVASCULAR: No cardiomegaly. S1 and S2 RRR without any skips, rubs, gallops or murmurs. GASTROINTESTINAL: Abdomen: Shape is flat, no tenderness, symmetrical, bowel sounds present x 4 quadrants, no masses, no hernias, no organomegaly. Abdomen soft, nontender to light and deep palpation x 4 quadrants. BACK: Normal, no scoliosis, no abnormal kyphosis.

FEMALE GENITALIA: Vulva: Bartholin glands normal. No atrophy or lesions noted. Urethral meatus normal, without discharge or irritation. Vagina: Mucosa pink and moist. Small amount of thin, clear non-odorous discharge noted. No evidence of prolapse. Cervix: pink, nonfriable without lesion or mass. Adnexa: Mobile, no palpable uterine or ovarian enlargement. Lymph: No inguinal lymphadenopathy.

ANUS AND RECTUM: No hemorrhoids or fissure noted.

MUSCULOSKLETAL: Normal gait and station. Extremities: No amputations or deformities, cyanosis, peripheral pulses intact. Right forearm, anterior side: solid, soft tissue swelling, with erythema, warm and pain to palpation. No open skin wounds with any type of drainage.

INTERGUMENTARY: Skin: Warm and dry, good turgor, no yellowish appearance, rash, unusual bruising or prominent lesions. Hair: Normal texture and distribution. Nails: Normal color, no deformities. NEUROLOGIC: Sensation intact to bilateral upper and lower extremities; CN 2-12 normal. Sensation to pain, touch and proprioception normal. DTRs normal in upper and lower extremities. Not pathologic reflexes.

PSYCHIATRIC: Oriented X3, intact recent and remote memory, normal mood and affect. HEMATOLOGIC/LYMPHATIC/ INMUNOLOGIC: No lymphadenopathy, no bruising

ASSESSMENT: 

Diagnosis: Menopausal and female climacteric states (ICD 10 N95.1). Common signs and symptoms include irregular menstrual periods, decreased fertility, vaginal dryness, hot flashes, sleep disturbances, mood swings, low libido, increased abdominal fat, thinning hair, and loss of breast fullness. (Jane, Davis, 2014). Patient reports experiencing two or three hot flashes per day. Mrs. ME also reports she is awakened from sleep, soaked by night sweats.

Differential Diagnosis :

Hyperthyroidism (ICD 10 E28.39). Hyperthyroidism is characterized by irregular menses, sweating (although different from typical hot flashes), and mood changes are all potential clinical manifestations of hyperthyroidism. (Jane, Davis, 2014). Patient reports experiencing two or three hot flashes per day. Mrs. ME also reports she is awakened from sleep, soaked by night sweats.

Polycystic Ovary Syndrome (ICD 10 E28.2) Polycystic Ovary Syndrome is characterized by infrequent periods or not peiods at all, difficulty getting pregnant (because of irregular ovulation or failure to ovulate) sweating or oily skin, hirsutism, acne, scalp hair loss, weight 6 gain and infertility (Jane, Davis, 2014). Patient reports experiencing two or three hot flashes per day.

Mrs. ME also reports she is awakened from sleep, soaked by night sweats.

PLAN 

– Pap Smear. Screening procedure for cervical cancer. (Jane, Davis, 2014).

-Mammography. Screening procedure for breast cancer. (Jane, Davis, 2014).

-Hormone tests to study hormonal function. (Jane, Davis, 2014).

– Luteinizing Hormone

-Follicle Stimulating Hormone – Estradiol – Progesterone – Prolactin

-Free T3

– Free T4

– THS

– Total Testosterone

– Free Testosterone

– DHEAS

– Androstenedione

Pharmacological treatment. 

Black cohosh root also seems to have some effects like the female hormone, estrogen. In some parts of the body, black cohosh might increase the effects of estrogen. (Liu, Reape, Hait, 2012).

Black cohosh (540 mg) 540 mg PO daily

Non-Pharmacologic treatment: – Avoid smoking – Avoid caffeine – Avoid spicy and sweet foods – Avoid tight clothing – Avoid heat and reducing the temperature in a room – Avoid stress – Avoid exercising in warm temperatures

EDUCATION: 

You have diagnosed with menopause and female climacteric; it is defined as the time in a woman’s life, usually between age 45 and 55 years, when the ovaries stop producing eggs (ovulating) and menstrual periods end. Menopause is complete when it has been 12 months since your last menstrual period. Hot flashes and night sweats are the most common symptom of menopause. Hot flashes typically begin as a sudden feeling of heat in the upper chest and face; the hot feeling then spreads throughout the body and lasts for two to four minutes. Some women sweat during the hot flash and then feel chills and shiver when the hot flash ends. Hot flashes are more common at night then during the day. When they occur during sleep, they are called “night sweats.” Night sweats may cause you to sweat through your clothes and wake you from sleep because you are hot or cold. You have been taken Black cohosh, because it can reduce some symptoms of menopause; you need to do lab test to confirm diagnosis and finally you will began taken estrogen because it is the most effective treatment for hot flashes. While there have been concerns in the past about the safety of hormone therapy, for most healthy women who are 8 seeking help with symptoms of menopause, it is safe, minimal risk, and effective. It should be started before the age of 60 years and is generally given for up to five years. (Liu, Reape, Hait, 2012).

REFERRALS: No referrals.

FOLLOW UP: Follow up at clinic in two weeks. Call office if your symptoms are worse.