WOMEN’S HEALTH MINI SOAP NOTES

WOMEN’S HEALTH MINI SOAP NOTES ICD 10: N39.0 S: Burning and pain with urination for 3 three days. Stated that her urine looks cloudy and has a foul odor. Denies fever, nausea, vomiting, myalgia, flank pain, blood in urine, any vaginal discharge, and, vaginal/vulvar irritation. She is sexually active, has same partner for last 4 years. G1P1001, with normal vaginal delivery. Menarche age 11. Last menses one week ago; regular 4- 5 days. Tested for STD one year ago. Negative for Chlamydia and Gonorrhea. O: Vitals: BP: 125/85 Pulse: 70 RR: 16 Temp: 98.1 W: 156 H: 5’6 BMI: 25.2. Pelvic exam was normal. A: 24-year-old female presented with 3-day complaints of burning and pain with urination. Cloudy urine with foul smell. Differential Diagnosis: Bacterial vaginosis or STD P: Labs: Urine culture: pending Medication: Cipro 250 mg PO q12hr for 3 days Education: Adhere to medication regimen. Instructed on personal hygiene; wash the perineal area from front to back and wear only cotton underwear. Avoid sexual intercourse until medication regimen has been completed and you no longer have symptoms. Increase fluid intake. Follow-up: If symptoms worsen, come back to office. Will call with test results in 48 hours. ICD 10: Z01.419; Z30.09 S: Yearly OB exam and refill BC. LMP was 3 weeks ago. Last pap & STD test one year ago. Menarche age 13. Sexual active with one lifetime partner. Uses condoms 50% of the time. G0P0. O: Vitals: Temp: 98.8: BP- 110/67: HR: 68: H: 5’7; W 178; BMI: 27.9. Pelvic exam: No bladder tenderness upon palpation, no distention noted. External genitalia normal, no gross lesions or lacerations. Vagina shows healthy, pink mucosa, no gross lesions, white discharge noted. Cervix shows no lesions. Wet prep has normal results. A: 19-year-old female presented for yearly OB exam, which after reviewing the patient’s records, it is noted that this is appropriate. Patient is sexually active and on oral contraceptives, therefore pap was recommended. Patient has requested a refill on her oral contraceptives and has discussed her usage of back up birth control when she occasionally misses a dose of medication. No differential diagnosis P: Labs: Pap smear: Pending; Wet Prep: Normal Medication: Tri Sprintec, 1 pill PO daily, disp #1, 11 refills Education: Encouraged patient to continue to use a backup form of birth control is OCs are missed. Reiterate the importance of taking this medication as directed and maintaining only one sexual partner. Oral contraceptives can cause DVTs. Do not smoke while taking OCs, as it increases the risk of DVT. Certain medications decrease the effectiveness of OCs. If you are placed on a new medication, ensure that interactions are checked. If you miss a dose, take that dose as soon as possible. If two doses are missed, take two pills immediately, then continue taking one pill daily. If this occurs, use a form of back up birth control for up to 7 days. The use of OCs do not prevent against the transmission of HIV, AIDS or other STDs. Begin self -breast exams on a monthly basis. Follow-up: Will call patient with test results if abnormal. Otherwise, schedule annual Pap for next year. ICD 10: N94.6; Z30.09 S: Follow up for severe menstrual cramps. LMP 12/15/17; occurs every 28-30 days. Days of flow: 3-5. Has missed one day of school every time she has a period. First menses age 13. Takes OCT Ibuprofen with no relief. Uses heat pad, helps a little with abdominal discomfort. Denies other symptoms such as vaginal discharge, dysuria, fever, or abdominal pain at times other than menstruation. Admits that she is sexual active with two life partners. Last sexual encounter was about a month or so ago. Uses condoms but not all the time. Has not had a pelvic exam not has been tested for STD, since her mother does not know that she has been sexually active and would not like her mother to find out. Interested in birth control. O: Vitals: Temp: 98.7, HR: 88, RR: 18, BP: 110/68; H: 5' 4, W: 113, BMI: 19.4; External: Tanner 5 pubic hair, normal genital development, no lesion. Internal: cervix- nulliparious, os closed, pink with no lesions. Scant clear mucoid discharge. Bimanual: anteverted uterus, normal size with no masses; adnexa- normal, non-tender. A: 16-year-old female Caucasian female, sexually active, with marked dysmenorrhea, in need of contraception. Parent not aware of sexual activity and patient prefers to keep it confidential today. Introduced oral contraceptive pills to patient and mother as a treatment for severe dysmenorrhea. Both mother and patient agreed to a 2-6 month trial of oral contraception along with high dose Ibuprofen. Differential Diagnosis: Endometriosis & PID P: Labs: Denied STD or pregnancy testing right now due to mother being present. Medication: Ortho-Cyclen 28 day. Dis: 1 pack. Sig: 1 tab po qd. Refill: 2 and Ibuprofen 600 mg Dis: 30. Sig: 1 TAB PO TID for dysmenorrhea. Refill: 3. Education: Educated on contraception usage. Informed contest signed. Encouraged condom use when patient’s mother was not present in room. Follow-up: 3 months ICD 10: N76.0 S: c/c “I have very bad smelling discharge from my vagina.” Patient stated that the discharge is thick white and has been ongoing for one week, heavier in the morning. Has not tried anything form of treatment thus far. Reports one regular sex partner (for a period of one year) and 7 lifetime partners. States does not always use condoms, but knows the importance of using them. LMP: 12/22/17. Last pap: Unknown. G2T1P1A0L1; Twins at 21 weeks via C-section due to complications with pregnancy. Denies any other symptoms pelvic cramping, dysuria, unusual vaginal itching or burning, or n/v. O: Vitals: Temp: 99.1, BP: 128/64, HR: 81, RR: 19, W: 162, H: 5’10, BMI: 23.2. PELVIC: ext. genitalia + vaginal walls pink, pubic hair scant and shaven, cervix intact, closed os, thick white foul smelling discharge noted in vaginal canal, lower pelvic tenderness on bimanual exam, uterus smooth and within normal limits, ovaries not palpable. A: 28 year-old Hispanic female presented with one-week history of bad smelling thick, white discharge from vagina. DX: Bacterial Vaginosis. Differential Diagnosis: Trichomoniasis, Gonorrhea, Chlamydia P: Labs: Gonorrhea, Trichomoniasis, and Chlamydia culture- results pending Medication: Flagyl 500 mg bid for 1 week Education: Take medication as prescribed. Do not drink any alcohol while taking this medication because it can cause nausea and or vomiting. Abstinence from any sexual encounters until medication regimen is completed and symptoms have are gone. Do not douche. Increase fluid intake. Follow-up: Will call with test results if positive and readjust medication if needed. If symptoms worsen, call office for appt. ICD 10: N73.9 S: c/c “I feel pain in my hips and bladder. I have been noticing occasional blood in my urine especially after sex and sometimes it hurts to pee.” Patient stated that there is blood in her urine but denies urinary frequency and urgency. She also verbalized whitish yellowish discharge; denies any foul odor or fever. She is worried about her recent sex partner and sounds disturbed about possibly having a STD. She denies any contraceptives on her part and does not use condoms. O: Vitals: BP: 113/59; HR: 67; RR: 18; Temp: 97.8; H: 5’3” W: 128lb; BMI 22.6. External genitalia without erythema, lesions or masses. No inguinal adenopathy. Vaginal mucosa pink, cervical redness & swelling noted with whitish yellowish homogenous discharge but no fishy or foul smelling odor, (+) chandelier sign (cervical motion tenderness). Cervix was friable upon swab sample collection and no visible discharge in the cervical os after collection. Uterus midline and no adnexal masses. Rectovaginal wall intact, without masses. A: 26-year-old Caucasian female patient came in with the concern of post coital bleeding, pelvic and bladder pain with occasional dysuria for the last three days. DX: PID. Differential Diagnosis: Mucopurulent Cervicitis & Acute cystitis P: Labs: CBC, urinalysis, cervical culture & wet prep, pending. Pregnancy test: negative Medication: Ceftriaxone 250 mg intramuscularly (IM) once as a single dose plus, Doxycycline 100 mg orally twice daily for 14 days Education: Take medication as prescribed and possible side effects. Avoid chemical irritants such as douches and deodorant tampons. A monogamous sexual relationship with someone who is known to be free of any STD can reduce the risk. Monogamous means you and your partner do not have sex with any other people. Consistent use of condoms greatly reduces the risk of transmission of STDs. Condoms are available for both men and women. A condom must be used properly every time. Increase fluids and urinate more. Recommended cranberry juice to acidify the urine. Encourage proper nutrition and regular physical activity. Follow-up: Return to the clinic immediately if worsening of symptoms such as persistent fever, chills, abnormal discharge or other signs of infection. Otherwise, follow up in two weeks. Call for any questions. ICD 10: N63 S: “I found a small non-painful lump in my right breast.” Found right-sided lump in breast while during monthly first exam two days ago. No pain but concerned about it being breast cancer, since her aunty (Mom’s sister) was diagnosed with breast cancer 5 years ago. Has never had a mammogram performed. O: Vitals: BP: 122/63, HR: 62 RR: 16 Temp: 98.2 W: 178, H: 5’7, BMI: 27.9. Breast exam: Upper area of right breast palpable, small painless solid mass detected. No dimpling or pitting of skin. No nipple discharge. A: 34-year-old African American female presented with non-painful right breast lump with a family history of breast cancer. DX: Unspecified breast lump Differential Diagnosis: Fibroadenoma or Fibrocystic condition, breast cancer P: Test: Mammogram/ Breast Ultrasound/Biopsy ordered- pending results Medication: None Education: The importance of performing monthly self-breast exams. Keep a journal of any changes of breast and any associated abnormal distinctions. Follow-up: Will call with mammogram results as soon as available. ICD 10: A60.00 S: c/c “I have multiple painful and itchy white pimple-like blisters on the outer part of my vagina.” Two-day history of painful and itchy blisters on outer area of vagina. Burns when urinating and nothing has helped to alleviate it. Last sexual encounter was 2 weeks ago. Uses condoms but not all the time. Admits to having 10 plus lifetime partners. LMP: 12/23/17. Last PAP, unknown. O: Vitals: BP 128/61, HR: 72, RR: 21, Temp: 99.5, H: 5’3, W: 121, BMI: 21.4. External vaginal exam revealed multiple 1-2 millimeter small white pus like lesions grouped in crops on vulva and labia. A: 27-year-old female present with multiple painful and itchy white pimple like blisters on her vagina. Symptoms began 2 days ago and stated that it burns when she urinates. DX: Genital Herpes Differential Diagnosis: HPV, Vulvovaginitis, Syphilis P: Labs: Viral culture, Polymerase chain reaction (PCR) test, CBC-pending Medication: Valtrex 1 g PO q12hr for 10 days Education: No cure for genital herpes. Take all medication as prescribed. No sexual relations until medication is complete. Must use condoms at all times. Wash your hands with soap and water before and after touching blisters. Keep the genital areas clean and dry. If it is painful to urinate, soak in a tub of warm water to relieve pain or try warm cloth compresses to reduce irritation. May use ice packs for pain relief. Use mild soaps. Wear loose fitting clothing. Do not wear panty hose or tight fitting jeans. Wear cotton underwear. Avoid touching the eyes after touching blisters. Herpes can spread to the eyes and cause serious infection, and in rare cases, blindness. Avoid reoccurring blisters. Stress, lack of sleep, and other infections can increase blisters. Healthy lifestyle behaviors can reduce the number and severity of blisters. Limit sexual partners. Practice safe sex. Follow-up: Seek medical attention of symptoms worsen. Come back in 2 weeks for follow up. Will call with lab results. ICD 10: N95.1 S: “I have been having hot flashes for the past few months, and I just can’t take it anymore.” Reports experiencing 2-3 hot flashes per day sometimes associated with insomnia. She also states she is awakened from her sleep, soaked by night sweats, about 1-2 times per week needing to change her pajamas and bedding. Her symptoms began about 6 months ago, and over that time, they have worsened to the point where they have become very annoying. LMP: About 4 years ago; some spotting but nothing major. Last PAP: year ago. She states that her mother was prescribed hormones for this, but she is cautious to take them because she has heard that the medication may not be safe.