+1(978)310-4246 credencewriters@gmail.com

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

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.
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.
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
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
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
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.Soap Note 1: Trichomoniasis vulvovaginitis. 1 Subjective: CC: “I’m having vaginal discharge and lower abdominal pain”. History of Present Illness: A 46-year-old, female of Hispanic origin who comes to our office and refers her has lower abdominal pain and vaginal discharge of five days duration, yellowish color and strong smell, Denies history of STDs, fever, vomiting, nausea. Reports Douches regularly after menses and intercourse. Denies nauseas, vomiting, menstrual troubles, headaches, or pain of other type. Race: Hispanic Past Medical History: None Past Surgical History: None OB History: G2P0T2A0L2. (Delivers into hospital without complications). Menarche at age 11, LMP 10 days ago. Immunizations: Current and complete. FMH: Father High Cholesterol; Mother HTN SOCHX: Does not smoke, nor alcohol or drugs. Lives with family Allergies: No known drug or food allergies Medications: None Marital Status: Married 14 years ago. Review of Systems: General: Denies malaise, chills, night sweats, weight gain, or weight loss. Integumentary: Denies rashes, pigmentation changes, lesions, or hair or nail changes. Eyes, ears, eyes, nose, and throat: Denies headache or dizziness. Denies blurred, double vision, or use of glasses. Denies earaches or hearing loss. Denies nasal congestion or stuffiness, SOAP NOTE 1: TRICHOMONIASIS VULVOVAGINITIS. 2 runny nose or nosebleed. No sinus pain or pressure. Visits dentist every 6 months. No trouble swallowing or slurred speech. Cardiovascular: Denies chest pain, palpitations, dyspnea, or orthopnea. Respiratory: Denies shortness of breath, dyspnea on exertion, cough, or wheezing. Gastrointestinal: Reports nausea and lower abdominal pain. Denies vomiting or blood in stool. Urinary: Denies urgency, dysuria, or urinary incontinence. GYN: refers has vaginal secretion yellow color, fish odor, no urinary symptoms reported. Musculoskeletal: Denies any history of falls and any loss of range of motion. Neurologic: Denies weakness, dizziness, lightheadedness, tremors, seizures, gait problems, speech difficulties, or memory problems. Endocrine: Denies heat or cold intolerance, polyuria, polydipsia, or history of diabetes. Psychiatric: Report slight anxiety due to malodorous vaginal discharge. Denies depression or any thoughts to harm self or others. Denies any hospitalization or institutionalization due to a psychiatric disorder. Denies any psychosocial/emotional disorder now. OBJETIVE DATA General: is awake, alert, and oriented to time, space, and person. Speaks clearly and follows simple commands. Well developed, well-nourished and in no acute distress. Vital Signs: BP 110/82 mmhg Pulse 82 x min, Respirations 16 x min, SOAP NOTE 1: TRICHOMONIASIS VULVOVAGINITIS. 3 Temperature 98.6 degrees Fahrenheit Pain scale 3/10, Height 5'6'' Weight 168 ps. SO: 100 %. Integumentary: Normal general appearance. Warm, moist, good skin turg

error: Content is protected !!