2023 I NEED A RESPONSE FOR THE 2 SOAP NOTES 1 IS BELOW

  I NEED A RESPONSE FOR THE 2 SOAP NOTES (1 IS BELOW THE OTHER ONE IS ATTACHED). It is not another soap note, it is a response to the peer who did the soap note

PATIENT INFORMATION

Name: Mrs.: M.B.

Age: 44-year-old

Sex: Female

Source: Patient

Allergies: None

Current Medications: Ibuprofen 400 mg, I tab when feels pain

PMH: Denies any disease.

Immunizations: Influenza this September 2019

Surgical History: None

Family History: Father- alive 66 years old, healthy

Mother-alive, 67 years old, Asthma

Daughter-alive, 15 years old, healthy

Social Hx: Smoking history, 2 packs a day, occasional alcoholic beverage consumption on social celebrations.

SUBJECTIVE:

Chief complain: “I have painful periods and pain following sexual intercourse”.

Symptom analysis/HPI:

The patient is 44 years old female hispanic, who complaining of painful periods and she also refers pain following sexual intercourse. She experiences occasional heavy menstrual periods and bleeding between periods. The symptoms starting 4 months ago, now are worse. The patient denies chest pain, palpitation, shortness of breath, nausea or vomiting. Denies any past medical condition.

ROS:

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss.

HEENT: HEAD: Denies any head injury or change in LOC. Eyes: Denies any changes in

vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or

drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain,

hoarseness, difficulty swallowing.

Respiratory: Patient denies shortness of breath, cough or hemoptysis.

Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea,

vomiting or diarrhea.

Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies

difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping

sound.

Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

NEUROLOGIC: Denies headache, dizziness or changes in LOC. Denies history of

tremors or seizures.

Objective Data

CONSTITUTIONAL:

Vital signs:

Temperature: 97 °F,

Pulse: 66 x min.

BP: 130/80 mmhg.

RR 18 x min.

PO2-98 % on room air.

Ht- 5’5”

Wt 162 pns

BMI 22.5 m2.

Report pain 0/10.

General appearance: The patient is alert and oriented x 3. No acute distress noted.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no

tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye

movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema,

or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary

sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions.

Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid

swelling or masses.

Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary

refill < 2 sec.

Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered

pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on

auscultation.

Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in

all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding,

no rebound no distention or organomegaly noted on palpation

Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no

stiffness.

Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.

Gynecologic exam: During a pelvic exam, no abnormalities such as cysts in the

reproductive organs or scars behind the uterus were found.

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.

Assessment:

ICD 10: N80.9; Endometriosis based in the patient’s symptoms. I order some tests to rule

out other conditions. Chronic inflammatory condition defined by endometrial stroma and glands

found outside of the uterine cavity. The most common sites affected are the pelvic peritoneum

and ovaries. May present incidentally in asymptomatic patients, or more commonly in women of

reproductive age who complain of chronic pelvic pain and/or subfertility. Clinical suspicion is

generally sufficient to initiate therapy, but the diagnosis can only be confirmed by direct

visualization and focused biopsies during laparoscopy.

ICD 10: Z12.4; Encounter for screening for malignant neoplasm of cervix.

Differential diagnosis:

ICD 10: N80.0; Adenomyosis; Symptoms may be identical to those of endometriosis.

Preoperative MRI findings may show diffuse or focal widening of the junctional zone (inner

myometrium), islands of endometrial tissue or cystic dilation of glands or hemorrhage, linear

striations radiating out from the endometrium into the myometrium, mass within the

myometrium (adenomyoma). Laparoscopy may reveal a normal pelvis or concurrent

endometriosis. Histopathologic evaluation of the uterus after hysterectomy shows endometrial

glands/stroma in the myometrium.

ICD 10: N30.10; Interstitial cystitis; Symptoms primarily localized to the bladder, such as

urinary frequency and urgency. Patients complain of pain with a full bladder that is relieved upon

voiding. Diffuse chronic pain and dyspareunia are common and often indistinguishable from

endometriosis.

ICD 10: Ovarian cyst (benign); May be asymptomatic with an incidental pelvic mass or

present with acute rather than chronic pain, such as in the case of hemorrhagic cysts.

Plan

Laboratory Exam:

Ultrasound. To identify cysts associated with endometriosis (endometriomas).

Magnetic resonance imaging (MRI). To obtain a detailed information about the location

and size of endometrial implants.

Pharmacological treatment:

Ibuprofen (500 mg) 1 tablet 4 times a day if you feel pain

Elagolix (Orilissa) – 1 tablet taken twice daily

Non-Pharmacologic treatment:

If the pain persists you can try measures at home to relieve the discomfort taking warm

baths and a heating pad, helping relax pelvic muscles and reducing cramping and pain.

Follow-ups/Referrals

Follow up: in 2 weeks to evaluate current treatment.

Referrals No needed at this time.