SOAP NOTE: Post-Menopause  bleeding assignment

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SOAP NOTE: Post-Menopause  bleeding assignment

SOAP NOTE: Post-Menopausia  bleeding.

STUDENT NAME

 

MRU

MSN6050 ADVANCE PRACTICE IN PRIMARY CARE- WOMEN’S HEALTH

PATIENT INFORMATION

Name: Ms. TM

Age: 57 years old

Race: Hispanic

Gender at birth: Female.

Gender identity: Female.

Source: Patient.

Allergies: Penicillin.

Current medications: Lisinopril 10 mg tab, 1tab daily.

Atorvastatin 20 mg tab, 1 tab daily.

Insurance: PPO.

PMH: Denies.

Surgical History: Appendectomy at 13 y/o.

Immunizations: Influenza. December 2020.

Preventive care: Last PAP smear August 2018. Normal.

Mammogram: Normal. BIRADS 0

Exposure: No knows HIV exposure during the last year. No blood transfusions or            received other blood components or tissues.

Environmental exposure was unknown to asbestos, radiations or other chemical substances. No exposure to the sunlight during day activities for long periods of time. SOAP NOTE: Post-Menopause  bleeding assignment

Family History: Father deceased CAD.

                            Mother alive: 85 y/o, HTN.

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Social History: Patient is heterosexual, single, and lives with her husband, roommate, and has a daughter 35 y/o. No domestic violence suspected or negligent behaviors. Client denies using drugs she said that she drinks alcohol only socially. Patient denies smoking tobacco or marihuana.

Nutrition history: She reports a healthy diet, low in sugar and salt.

Chief complaint: “I have my period again”

History of present illness: The patient is a Hispanic female, 57 y/o, G1T1P0A0L1, that

comes to the office staying “I have my period again”. She reports that she has watery, bloody

vaginal discharge for 2 weeks. This never happen before. Her last menstrual period was around 8

years ago. The client denied having had vaginal discharge. She is divorced for three years ago

and she did not have sexual activity since that time. The las pap test was in 2018, and the result

comeback negative. She denies history of sexual assault or trauma, also reports mild

discomfort on pelvic area, no fever or chills. There is not change on her appetite, no weight loss, malaise or weakness.

No previous hospitalizations or invasive procedures in the past twelve months. No history of

mental illness. No physical trauma or falls reported during the last year. SOAP NOTE: Post-Menopause  bleeding assignment

 

HPI- Women’s Health part:

Menstrual history: Monthly, denies clot or  bleeding.

Age of Menarche: 11 yo

Last menstrual period: 2013.

Bleeding pattern. Reports vaginal bleeding during the last 2 weeks.

Associated pain (dysmenorrhea): N/A.

Break through bleeding: N/A.

Length of cycle: N/A.

Average number of days of menses: N/A

Pre-menopause/menopause: Yes. Vasomotor symptoms: Yes.

Hormone replacement therapy: No.

Condom use: No.

Vaginal douches: No.

Level of satisfaction with sexual activity: good

History of sexual assault: no

Contraceptive use: N/A.

Previous method, including complications, reason discontinued: Same method.

Cervical and vaginal cytology: 2013. Normal

Most recent PAP Smear: Normal.

History of abnormal PAP Smear? Denies.

History of sexually transmitted infections: She denies having had any sexually transmitted disease.

Vaginitis: Denies. History of Pelvic inflammatory disease? Denies.

Any difficulty conceiving in the past? Denies.

Sexually active: Yes, she has a fixed partner for the last 35 years.

SOAP NOTE: Post-Menopause  bleeding assignment

 

 

 

Obstetric history:

G 1

T 1

P 0

A 0

L 1

Describe any maternal, fetal, or neonatal complications? Denies.

REVIEW OF SYSTEMS:

CONSTITUTIONAL: Denies fever, chills or malaise. Denies low energy in the past two weeks as identified in the PHQ-9 questionnaire. Denies weight loss, change of appetite.

NEUROLOGIC: Denies headache, changes in LOC, history of tremors or seizures, weakness, numbness, dizziness, headaches. Denies trouble walking, syncope, sleep disorder, memory problems.

PSYCHIATRIC:  Mood was euthymic, not feeling restless or anxiety. No feeling hopelessness or depressed. No sleep disturbances, trouble falling or staying asleep. Normal enjoyment of activities. Not easily distracted and no change in thought patterns.

HEENT: Head:  Denies head injuries, or change on LOC. Eyes: No irritation, no drainage, no dry eyes, no pain on eyes’ structures or retro-orbital, no vision changes, no diplopia, or blurred vision. Ears: Denies loss of hearing, no ear pain, no drainage, no sensation of ears feeling full, no ear ringing, or ears’ trauma. Nose: Denies nasal congestion, no nasal drainage, no nosebleeds, and normal smell sense. Throat/Mouth: Denies sore throat, no hoarseness, no difficulty swallowing, or postnasal drip. No mouth sore, no thrush, no bleeding gums, no lips sore, no teeth problems.

NECK: Denies neck pain, no masses, no nodules, no history of thyroid abnormality.

RESPIRATORY: Denies chest congestion or wheezing, coughing, shortness of breath.

CHEST/ BREAST: Denies chest abnormalities, no breast lumps, no nodules, no nipple drainage, or nipple retraction.

CARDIOVASCULAR: Denies chest pain, palpitations. No orthopnea, or paroxysmal nocturnal dyspnea. Denies edema, irregular heartbeat, low or high blood pressure, poor circulation, cold extremity, or claudication.

GASTROINTESTINAL: Normal appetite as identified in the PHQ-9 questionnaire. No dysphagia or heartburn. No nausea, vomiting or abdominal pain. No hematochezia. No diarrhea or constipation. SOAP NOTE: Post-Menopause  bleeding assignment

GENITOURINARY: Denies dysuria, frequency, urgency, hesitancy, incontinence, nocturia, or

hematuria. No history of UTI and kidney infections

EXTERNAL GENITALS: The patient reports watery, bloody vaginal discharge for 2 weeks

and mild discomfort over the pelvic area. No history of STD.

MUSCULOSKELETAL: Denies fall, muscle or joint pain. Denies hearing a clicking or snapping sound. Denies numbness, hemiplegia o paresthesia, muscular atrophy or weakness. Denies limited range of mobility, joint pain or limited ROM.

HEMATOLOGIC: Denies easy bruising, loss of hair, heat/cold intolerance, changes in nails, enlarged glands, prolonged bleeding, increased thirst, or hunger.

SKIN: Denies skin rash, no wound, no change on skin color or texture, no change in a mole, no unusual growth, no dry skin, no itching, or jaundice. Hair: Denies hair loss, no hair abnormalities. Nails: Denies nails abnormalities, no discoloration, no clubbing, no cyanosis, or longitudinal ridges.

OBJECTIVE DATA:

VITAL SIGNS: Temperature: 97.9 F0, Pulse: 86 BPM, BP: 123/77., RR: 18 per min.

 

PO2- 98 % on room air.

SOAP NOTE: Post-Menopause  bleeding assignment

Gynecological examination was performed in the office.

 

GENERAL APPEARANCE:  Patient alert and oriented. Speech fluently. Patient does reflex discomfort in her face and posture secondary to the pain on her genitals

NEUROLOGIC: Alert, CNII- XII grossly intact, Oriented to person, place and time. Sensation: Intact to Bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. Romberg is negative and the patient has stable and balance gait. Reflexes 2 + symmetrical with negative Babinski. No asterixis. Proprioception was normal

PSYCHIATRIC: Cooperative but stressed about her genital condition. Patient is euthymic. The affect was normal.

HEENT: HEAD:  Normocephalic, atraumatic. Symmetric, nontender. Maxillary sinuses, no tenderness. Scalp pink and dry. EYES: No conjunctival secretion or injection, no icterus, extraocular eye movement intact.  No nystagmus noted. Symmetrical pupils, light reactive, Visual acuity 20/20 with the use of reading glasses. EARS: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light.  Maxillary sinuses no tenderness. NOSE: Nasal mucosa moist without bleeding. Clear nasal discharge. MOUTH AND THROAT: Oral mucosa moist without internal lesions such as canker sores, ulcers or vesicle. Tongue and uvula movement preserved without deviations.

NECK:  No pain, no cervical lymphadenopathy, no jugular vein distention the palpation thyroid is mobile when the patient swallows, centrally located without evidence, or increased in size, trachea is midline. No murmur at the level of the carotid arteries. No visible mass and skin with normal coloration. No palpable masses or tenderness, thyroid without nodules, no JVD, no lymph nodes. Pharynx: Moist and pink without tonsillar enlargement. No noted lesions or exudate.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no S3 or S4, no murmurs or gallop noted, PMI at 5th intercostal space, midclavicular line. No pericardial friction rub heard.

All pulses 4+ palpable and equal. No clubbing, cyanosis or edema noted. Bilateral carotid arteries without bruits. Capillary refill test < 2 sec.

RESPIRATORY:  Respirations are regular, equal, and unlabored with symmetrical chest expansion. No egophony whispered pectoriloquy, or tactile fremitus, on palpation. Breath sounds presents and clear bilaterally, on auscultation. No wheezing, stridor, crackles, or rhonchi noted. No increased tactile fremitus noted. Lungs resonant.

CHEST: Breast: Normal in size. Symmetric. Two normal nipples without discharge. No skin changes (rashes, lesions, dimpling or retraction).  No masses or tenderness. SOAP NOTE: Post-Menopause  bleeding assignment

GASTROINTESTINAL: Inspection: Symmetric, no distended no visible masses. The skin

is normal, appendectomy 4 cm scar located on RLQ. Auscultation: Bowel sound active in all 4

quadrants. No bruits. Palpation: Abdomen soft, mild tenderness on lower abdomen, non

distended, no masses, herniation, guarding, rebound tenderness. No hepatomegaly or

splenomegaly. Percussion: Normal.

GENITOURINARY:

External genitalia: Mons normal hair distribution, no lesions. Labia majora, minora and

clitoris normal. Bartholin’s and Skene’s glands normal. Urethra WNL.

Vagina: Rugate, pink/red, inflamed wall, no discharge, good tone, no cystocele,

rectocele or masses.

Kidneys: Both kidneys have normal size, they are not palpable. Costovertebral angles are

not tender on palpation and percussion. The bladder is not palpable or tender.

Cervix: Small, no lesions, masses, inflammation, bloody discharge, negative for cervical

motion tenderness, no ectropion.

Uterus: Big firm, lateral, hard and not mobile, tender to motion.

Adnexa: Thickness of right parametrium. Ovarium not palpable.

MUSCULOSKELETAL: No evidence of atrophy, tumor. No pain to palpation.  Active and passive ROM within normal limits, no stiffness. No peripheral edema. Stable gait.

INTEGUMENTARY: Intact, no cyanosis or jaundice, Nail without alterations: no mycosis, angle 160 degrees (no clubbing). Hair distribution in the preserved leg area, no area of paleness or redness, symmetrical calf diameter.

SOAP NOTE: Post-Menopause  bleeding assignment

ASSESSMENT:

Main Diagnosis: Postmenopausal bleeding. ICD 10 N95.0-). Postmenopausal bleeding: refers to any uterine bleeding in a menopausal woman, it occurs on 5% of the postmenopausal population, and between 6-19 % is due to Endometrial cancer. In general, all postmenopausal women with unexpected uterine bleeding, should be evaluated for endometrial carcinoma, which is a lethal disease cause of bleeding, however, the most common cause of bleeding in these women is atrophy of the vaginal mucosa or endometrium; in the early menopausal years, endometrial hyperplasia, polyps, and submucosal fibroids are also common etiologies. (Goodman et al 2021). This patient present to the office after her menopause years ago, with symptoms, signs, and physical examination correlated with Post-menopausal bleeding. We must rule out the Endometrial Carcinoma as a cause of postmenopausal vaginal bleeding, discomfort on lower abdomen.

Also, the positive findings at bimanual vaginal examination of big firm, hard, lateral uterus, not mobile, tender to motion, thickness of right parametrium place that option the first in line.

The Differential diagnosis are with:

Cervical polyps: The cause is unknown, but inflammation play an etiologic role, the

principal symptoms are discharge and abnormal vaginal bleeding, the polyps are visible in the

cervical os on speculum examination. (Papadakis &amp; McPhee, 2017)

Post-coital vaginal laceration: Appears frequently in postmenopausal women with

atrophic vagina due to low levels of estrogens. It is not uncommon to experience some amount

superficial trauma or tears to the vagina especially after a lengthy session of intercourse. It is

usually, painless. However, at times, the trauma to the vagina can be quite extensive, requiring

emergency intervention (Domino, 2017). SOAP NOTE: Post-Menopause  bleeding assignment

Atrophy of the endometrium and vagina: Secondary to the hormonal changes of the

menopause the hypoestrogenism could cause changes included atrophy of the endometrium and

vagina. It produces micro erosions of the epithelium, associated to chronic inflammation, and it

facilitate the bleeding. Then during the examination, you can find a dry vaginal epithelium that it

is smooth and shiny with loss of most rugation. Then, the blood vessels could be visible, and

there is a chance of bleeding. (Goodman et al 2021).

Endometrial Hyperplasia: It is a frequent cause of vaginal bleeding on menopause women.

Despite the expected decrease of the endogenous estrogen production, secondary to ovarian or

adrenal tumors or exogenous estrogen therapy, we can find endometrial hyperplasia, therefore,

patient can present with vaginal bleeding. (Goodman et al 2021).

 

Differential Diagnosis:  

  • Endometrial Hyperplasia (ICD 10 N 85.00)
  • Atrophy of the endometrium and vagina (ICD 10 N95.2)
  • Cervical polyps: (ICD10. N84.1)

 

Plan:

Lab/Tests: CBC with Diff, CMP, Lipid Panel, SR, UA, Vaginal and cervix culture, Pap

smear test, Abdominal and Transvaginal US.

Pharmacological treatment:

None at this moment

Non-Pharmacological treatment:

None at this moment.

Education: Patient is educated on possible causes of post-menopausal bleeding,

importance of lab/test ordered to set diagnosis, management, when to contact physician. Also, SOAP NOTE: Post-Menopause  bleeding assignment

the client is advised that the bleeding becoming heavy or she feels weakness contact the

physician or go to the near emergency room. The patient is instructed on the importance to

regular screenings. This can help detect conditions before they become more problematic.

Maintain a healthy weight, following a healthy diet and exercising regularly. This alone can

prevent a variety of complications and conditions throughout the entire body.

Follow-ups/Referrals. Return in 3 days after lab/test done to be re-evaluated and referral

to gynecologist if required.

 

                                            References

  1. Domino, F. J. (2017). The 5- minute clinical consult. (25th ed.). Philadelphia, PA: Wolters

Kluwer.

  1. Goodman, A., & Barbieri, R. L. (2021, February 2). Postmenopausal uterine bleeding. Retrieved February 06, 2021, from https://www.uptodate.com/contents/postmenopausal-uterine-bleeding?search=Postmenopausal%20bleeding&source=search_result&selectedTitle=1~79&usage_type=default&display_rank=1
  2. Hacker, N. F., Joseph, G. C., &amp; Calvin, H. J. (2016). Hacker &amp; Moore' s Essentials of Obstetrics and Gynecology. (6 ed.). Missouri: Elsevier.
  3. Papadakis, M. A., &amp; McPhee, S. J. (2017). Medical diagnosis and treatment (56th ed.). San Francisco, CA: Mc Graw Hill Education.

Grading Rubric

 

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

 

  • Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

 

  • Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

 

  1. a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).
  2. b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).
  3. c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

 

  • Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

 

  1. Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).
  2. Pertinent positives and negatives must be documented for each relevant system.
  3. Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

 

  • Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

 

  • Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

 

  • Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

 

  • Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

SOAP NOTE: Post-Menopause  bleeding assignment

Comments:

 

Total Score: ____________                                                          Instructor: __________________________________

 Guidelines for Focused SOAP Notes

  • Label each section of the SOAP note (each body part and system).
  • Do not use unnecessary words or complete sentences.
  • Use Standard Abbreviations

S: SUBJECTIVE DATA (information the patient/caregiver tells you).

Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.

History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.

Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.

Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.

Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.

Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic.  The ROS should mirror the PE findings section.

0: OBJECTIVE DATA (information you observe, assessment findings, lab results).

Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.

Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing.   The focused PE should only include systems for which you have been given data.

NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.

Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.

A: ASSESSMENT:  (this is your diagnosis (es) with the appropriate ICD 10 code)

List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.  SOAP NOTE: Post-Menopause  bleeding assignment

Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.

Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es).

For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.

P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.

  1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.
  2. Additional diagnostic tests include EBP citations to support ordering additional tests
  3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.
  4. Referrals include citations to support a referral
  5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.

 

SOAP NOTE: Post-Menopause  bleeding assignment