MSN 5500 Soap Notes #9 DYSMENORRHEA- 100% Complete

Encounter date: 10/09/17 Patient Initials: H.T. Gender: Female, Age: 19 years Weight 124 Height 5.6 Pregnant:0 Gestational Age: None. Abort: 0. Chief Complaint:” my cycles are so unpredictable and irregular and painful” HPI: A 19­year­old Hispanic female patient who came to the office for patient presents for her first gynecological exam with complaints of irregular periods and painful and reports she only has 7­8 periods per year on average since beginning her cycles at 11 years old. Denied pain at this time. Menstrual history: Irregular 28­day menstrual cycles, duration for 9­10 days irregular, and no report intermenstrual bleeding Age at menarche: 11 years Last menstrual period: 09/10/17 Menstrual pattern: Irregular Cycle: length: 32 days Duration of flow: 9­10 days Amount of flow: Heavy menstrual flow Bleeding pattern: report intermenstrual bleeding associated pain (dysmenorrhea) Break through bleeding: None Pre­menopause/menopause: Yes (dysmenorrhea) Vasomotor symptoms: no Hormone replacement therapy: no Contraception: No Current method: No Cervical and vaginal cytology: Yes, last year. Most recent Pap smear result: NO History of sexually transmitted infections: None Vaginitis: None History of pelvic inflammatory disease: None Any difficulty conceiving in past: None Sexually active: No History of sexual abuse or sexual assault: None Obstetric history: G­0 T­0