SOAP Note

Patient Initials:           RA Pt. Encounter Number: 1

Date: 10/1/20 Age: 23 Sex: female

Allergies:    NKA                                                                              Advanced Directives:      none

SUBJECTIVE

CC: “I have been having heavy periods for 4-5 months now. I feel tired and dizzy most days”

HPI: 23-year-old came to the clinic today complaining of heavy menstrual periods happening for the past 4 to 5 months. Accompanying the heavy flow, patient states that she has moderate cramps. Pt describes the pain as stabbing and its 3 out of the 0-10 scale. Patient does not take any medications for the pain. The pain is decreased by applying warm compresses to the lower abdominal area. In addition, patient complains of feeling dizziness and tiredness most of the times.

Current Medications: none

PMH  Medication Intolerances: NONE  Chronic Illnesses/Major traumas: NONE Screening Hx/Immunizations Hx: Vaccinations up to date, most recent pap smear 12/19 – negative  Hospitalizations/Surgeries: None

Family History:Father: Alive, No medical history Mother: Alive, Htn

Social History: Patient is a full-time college student and part time employee at Publix as cashier. Pt lives at home with parents and denies having had a sexual partner for the past year. Patient denies the use of cigars, alcohol, or illegal drugs.

ROS

GeneralDenies recent weight loss, fever, change in appetite or headaches. She denies chills or night sweats. CardiovascularDenies palpitations, chest pain, orthopnea, and claudication. Reports episodes of hypotension.

SkinDenies bruising, skin rash, or discoloration. Denies changes in moles or skin breakdown. RespiratoryDenies shortness of breath, abnormal sputum, cough, or wheezing.

EyesDenies pain, redness, loss of vision, double or blurred vision GastrointestinalDenies abdominal pain, decreased appetite, nausea, or vomiting. Denies food intolerances and changes in stool

EarsDenies ear pain, ear infections, or tinnitus Genitourinary/GynecologicalDenies dysuria, flank pain, and hematuria. Denies abnormal vaginal discharge or itching. Denies STI history. Reports heavy menstrual periods lasting 5 to 6 days, associated with cramping; every 28 days. OBSTETRIC/GYNECOLOGICAL Hx:Menarche:  11 years                       LMP: 09/15/20                       G 0 T 0 P 0 A 0 L 0               Birth Control/Type: NoneMenopause:  no                           Sexually Active: yes STD Hx:  None

Nose/Mouth/ThroatDenies nasal pain, congestion, epistaxis, or postnasal drip. Denies pain in mouth, bleeding gums, or dry mouth. Denies pain in throat, hoarseness, difficulty or painful swallowing. MusculoskeletalDenies muscle pain or joint pain. Denies limited range of motion

BreastDenies breast tenderness, discharge, redness, or lumps. NeurologicalDenies headache, dizziness, seizures, or memory loss.

Heme/Lymph/EndoPt denies bruising PsychiatricDenies mood changes, irritability, or changes in concentration. Denies having depressive ideation.

OBJECTIVE

Weight 119           BMI 21.08 Temp 98.0 BP 106/60

Height 5’3” Pulse 99 Resp 20

PHYSICAL EXAMINATION

General AppearanceCooperative, Hispanic woman, appearing in no distress, well-nourished and maintains appropriate eye contact.

SkinNo skin lesions or discoloration noted.

HEENTHead normocephalic with normal hair distribution. No lesions or masses noted. Eye: PERRLA intact, EOMs intact. Fundoscopic exam unremarkable. Ears: Tympanic membrane intact and pearly grey. Nasopharynx: no exudate, lesions, erythema, or discoloration. Mouth: Good dentition. No lesions or discoloration. Uvula midline, tonsils noted 1+.

CardiovascularS1, S2 with regular rate and rhythm. No carotid bruits. Capillary refill 2 seconds. Pulses 3+ throughout.

RespiratorySymmetric chest wall. Respirations regular and unlabored. Lungs clear to auscultation bilaterally.

GastrointestinalAbdomen soft and nontender. No mass or bruit noted. Normoactive bowel sounds present x4

BreastNo lumps or masses. No nipple retraction or discharge. No lymphadenopathy.

GenitourinaryNo bladder distention or CVA tenderness. On pelvic examination, menstrual bleeding is noted.

MusculoskeletalFull ROM, muscle strength 5/5. No crepitus, joint clicks or pain

NeurologicalCranial nerves intact. Motor and sensory intact.

PsychiatricAwake, alert, and oriented x 3, responsive to verbal and tactile stimuli.

Lab Tests80025: BLOOD COUNT; COMPLETE CBC, AUTOMATED & AUTOMATED DIFFERENTIAL WBC83540: IRON83550: IRON BINDING CAPACITY82728: FERRITIN84466: TRANSFERRIN76830: ECHOGRAPHY, TRANSVAGINAL

Diagnosis

Primary Diagnosis- D50.9 Iron Deficiency Anemia: The objective and the subjective information obtained support the suspected diagnosis for Iron Deficiency Anemia (Kocaoz, Cirpan, & Degirmencioglu, 2019). In addition, all the symptoms manifested such as the fact that she is feeling more tired than usual, abnormally heavy menses, associated with moderate to severe abdominal cramps and a family history, contribute to select this diagnosis as a final diagnosis.

Differential diagnoses:

 D25.9 Leiomyoma of Uterus, Unspecified: Benign tumors also known as fibroids. The tumors arise from the overgrowth of tissue and muscle in the uterus. Common symptoms include heavy menstruation and pelvic pain. This condition is unlikely to be the main diagnosis because the patient is not complaining of pelvic pressure (Sabry & Al-Hendy, 2019). 

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 N80.1 Endometriosis of Ovary: Occurs when extra tissue outgrows to the ovaries. Common symptoms include painful periods, pain with intercourse, excessive bleeding and infertility (Alimi, Loukas, & Tubbs, 2018). 

C54.1 Malignant neoplasm of endometrium: A malignant condition that occurs when the abnormal growth of cells appear in the endometrium (Parasar, Ozcan, & Terry, 2017).  The cells can also spread to other organs. Vaginal bleeding and pain are the most common first manifestations. In this case, this condition is unlikely because the patient is having heavy bleeding associated with menstruation (Porter, 2020).  

PLAN including education Test: 

CBC, Serum iron, Transferring saturation, Total Iron-binding capacity, Serum Ferritin, Transvaginal UltrasoundMedications: None at this time until lab work is evaluated. Birth Control options discussed with patient at this time. Education: Patient was educated on safe sex practices and self-breast examination. Patient was educated to eat diet high in iron including red meat, pork and poultry, seafood, beans, dark green leafy vegetables, such as spinach, dried fruit, and raisins. Increase fluid intake. Follow up in 2 days for results.

References

 Alimi, Alimi, Y., Iwanaga, J., Loukas, M., & Tubbs, R. S. (2018). The Clinical Anatomy of Endometriosis: A Review. Cureus, 10(9), e3361. https://doi.org/10.7759/cureus.3361

Kocaoz, S., Cirpan, R., & Degirmencioglu, A. Z. (2019). The prevalence and impacts heavy menstrual bleeding on anemia, fatigue and quality of life in women of reproductive age. Pakistan journal of medical sciences, 35(2), 365–370. https://doi.org/10.12669/pjms.35.2.644

Parasar, P., Ozcan, P., & Terry, K. L. (2017). Endometriosis: Epidemiology, Diagnosis and Clinical Management. Current obstetrics and gynecology reports, 6(1), 34–41. https://doi.org/10.1007/s13669-017-0187-1

Porter S. (2020). Endometrial cancer. Seminars in oncology nursing, 18(3), 200–206. https://doi.org/10.1053/sonu.2002.34082

Sabry, M., & Al-Hendy, A. (2019). Medical treatment of uterine leiomyoma. Reproductive sciences (Thousand Oaks, Calif.), 19(4), 339–353. https://doi.org/10.1177/1933719111432867