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SOAP NOTE

TOPIC: CYSTITIS

APA

REFERENCE LESS THAN 5 YEARS

FEMALE ADULT PATIENT

Demographic Information
Encounter Date:
Patient initials:
Age:
Race:
Gender:
Insurance:
Information Source:
SUBJECTIVE
Chief complaint:
History of present illness (HPI):
Allergies
Medication History:
Family History
Patient History
Past Medical History (PMH):
Genetical History: Negative Infection History:
Menstrual History:
LMP:
Menses Monthly:
Prior Menses:
Frequency:
Menarche:
On Contraception Tx:
The current method of contraception is used:
Menopause: Fertility:
Sexual history:
Obstetric History
Total Preg. Full Term Premature Ab Induced Ab Espontan Ectopic
Date:
GA week
Weigh
Sex
Hospitalization:
History of mental illness/personality disorders:
Physical trauma/falls:
Surgeries:
Exposure:
Immunizations:
Exercise:
Diet:
Social History:
Deliver
Complicity
Multiple Living
Educational level:
Sexual Behavior:
Last annual physical exam:
Screening:
Pap smear:
HIV /STD Test:
Monthly Breast Self-examination: Mammogram:
Bone density:
Colon cancer Screening:
Skin cancer Screening:
REVIW OF SYSTEM:
Systemic:
HEENT:
Head:
Neck:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Gynecological:
Breast:
Endocrine:
. Hematologic.
Musculoskeletal:
Neurological:
Psychological
Integumentary:
OBJECTIVE:
Physical Exam
Vitals Signs.
General appearance:
Head.
Neck
Eyes: Ears:
Nose:
Oral Cavity:
Pharynx:
Lymph Nodes:
Chest:
Lungs:
Cardiovascular.
Abdomen:
Genitourinary:
Gynecological:
Inspection:
Palpation
Speculum exam for Vagina and cervix.:
Bimanual exam:.
Pregnancy test
Breast: Inspection:
Palpation:
Endocrine:
Hematologic:
Musculoskeletal:
Neurologic:
Psychiatric:
Integumentary:
ASSESSMENT :
Main diagnosis:
Differential diagnosis:
1.
2.
3.
PLAN:
Diagnostic tests :
Pharmacological treatment:
Non-pharmacological measures:
Patient education:
Follow-up/Referrals:
Follow-up:
Referrals:
1
SOAP Note # 1 Dysmenorrhea
Dysmenorrhea
2
SOAP Note # 1 Dysmenorrhea
Demographic Information
Encounter Date: 05/03/2020
Patient initials: M.G.
Age: 33 y/o
Race: Hispanic
Gender: Female
Insurance: Humana PPO
Information Source: Patient
SUBJECTIVE
Chief complaint: “My period is being terribly painful”
History of present illness (HPI): 33 y/o Hispanic female who presents to the medical office
complaining of a “painful period”, being more marked two days ago (the 1st day of the menstrual
period) even though today (3nd day) continue to be alike intensive described with a rating between
4-6/10. The pain started a few hours after the menstruation, it is located in the lower abdomen
without radiation, and is described as sharp and intermittent, increasing the intensity as the flow
reach it maximum peak. The pain is not accompanied by any other symptoms. No medication has
been taken, but warm compresses have been being applied which temporarily relieves the pain but
does not definitive eliminate it. As the patient states, this is the first time the described clinical
picture occurs.
Allergies: NKA.
SOAP Note # 1 Dysmenorrhea
3
Medication History: No medication
Family History
Mother Alive 58 y/o /Positive Hx: HTN
Father Alive: 60 y/o/Positive Hx: HTN
2 Brothers Alive 35/29 Healthy
Negative Hx for Cancer, Dead for CV event , Genetical disease
Patient History
Past medical History (PMH): Negative for Chronic Disease
Genetical History: Negative
Infection History: Negative
Menstrual History:
LMP: Current 05/01/2020
Menses Monthly: Yes
Prior Menses: 03/31/2020
Frequency: 5-6 Days Q/ 30 days
Menarche: 13 y/o
On Contraception Tx: No
Current method of contraception being used: Condom, expresses satisfaction with the mentioned
method.
Menopause: N/A
Fertility: No difficulty conceiving.
Sexual history: Denies history of sexual dysfunction.
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SOAP Note # 1 Dysmenorrhea
Obstetric History
Total Preg.
Full Term
Premature
Ab Induced
Ab Espontan
Ectopic
Multiple
Living
1
1
0
0
0
0
0
1
Date:
GA week
Weigh
Sex
Deliver
Complic
10/25/2011
38
7.5
Male
Vaginal
No
Hospitalization: No previous hospitalization.
History of mental illness/personality disorders: None.
Physical trauma/falls: No reported during the last twelve months.
Surgeries: Tonsillectomy at the age of 8 years. No previous gynecologic surgeries.
Exposure: Patient is living in an apartment and does not complaint of any financial difficulties.
No knows HIV exposure during the last year. No blood transfusions or other blood components or
tissues have been received. No identified environmental exposure to asbestos, radiations or any
other chemical substances. No exposure to the sunlight during the regular daily activities.
Immunizations: Vaccines updated (Flu Vaccine: 10/30/2019).
Exercise: No engage in any regular exercise’s regimen.
Diet: Patient does not follow a specific diet. The diet is rather rich in carbohydrate and proteins.
Social History: Patient is well socially integrated, non-smoker, does not consume any drink
alcohol based. Consume coffee at least once a day. Denies using illegal drugs. She is a secretary
in a Lawyer office. Lives with her husband and her 8 y/o son. She describes her home dynamic,
functional and happy.
SOAP Note # 1 Dysmenorrhea
5
Educational level: High school completed.
Sexual Behavior: Patient is heterosexual and has a stable sex partner (her husband). No
identified risk behavior for STDs.
Last annual physical exam: 4/26/2019
Screening:
Pap smear: 04/26/2019: Negative
HIV /STD Test: 4/26/2019: Negative
Monthly Breast Self-examination: Yes
Mammogram: N/A
Bone density: N/A
Colon cancer Screening: N/A
Skin cancer Screening: 4/26/2019
REVIEW OF SYSTEMS:
Systemic: No fever reported. Denies fatigue or weight loss.
HEENT. Head: No history of trauma, no complaining of headache. No sinus pain or any other
facial pain is stated.
Neck: Denies pain or stiffness. No swollen glands in the neck. Eyes: Denies blurring vision,
double vision, redness or eye discharge. Oto-laryngeal: Denies change in hearing, ringing in ears,
pain or discharges from external auditory canal. Denies watery nose discharge, congestion or nasal
bleeding. Denies bleeding gums. No hoarseness.
Cardiovascular: Denies chest pain, palpitation or edema on the lower extremities. No varicosities
or history of DVT.
Respiratory: Denies shortness of breath, cough or wheeze. No complaints of chest congestion.
SOAP Note # 1 Dysmenorrhea
6
Gastrointestinal: Denied appetite problems. No dysphagia. Denies heartburn or bleeding. No
complaints of flatulence. Denies nausea or vomiting. Denies hematochezia. No diarrhea or
constipation. Last bowel movement: 5/3/2020 ( today)
Genitourinary: Denies changes in urinary habits, normal urinary frequency, denies urgency,
nocturia or hematuria. Denies history of kidney stones, flank pain, cloudy urine or bad smell.
Gynecological: Complaining of pain during the menstrual period, which started a few hours after
the menstruation starting and it was more marked the 1st day of the period, extending to the 3nd day
(today) it is characterized as sharp and intermittent or spasmodic, located in the suprapubic area
without any radiation. The intensity increases as the flow reach it maximum peak. No
accompanying symptoms. A mild, temporal relieve is found with application of warm compresses.
Cycle length normal but is accompanied of mild pain on the lower abdomen as usual happen during
each period, it is described as no copious bleeding with a few small clots, duration. No bleeding
between menstruation period. Denied vaginal discharge, no itching, no sexual problems, no pain
with intercourse.
Breast: No any mass noted, no fulness sensation, pain or discharge reported. No prior
history of breast biopsy, lesions, pain or discharge.
Endocrine: Denies hot or cold intolerance, polyuria or polyphagia. Denies thyroid problems.
Hematologic: Denies anemia, bruising, adenomegaly, unusual bleeding, petechiae, left upper
quadrant orbone pain.
Musculoskeletal: No any history of falls reported, denies weakness, muscular pain, swollen or
any other inflammatory symptoms in the joints. Denies joint pain, limited ROM, difficulty walking
or trouble reaching above head.
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SOAP Note # 1 Dysmenorrhea
Neurological: Denies loss of memory, seizures, seizures or fainting lightheadedness, facial pain,
gait imbalance or changes in LOC. Denies tremors, muscle weakness, numbness, tingling or
sleeping disturbances.
Psychological: Patient states no changes in mood, denies anxiety, depression or insomnia. Denies
low self-esteem, feeling sad, social isolation or attention deficit, no change in thought patterns.
Enjoyment of activities is sometime interrupted during the pain.
Integumentary: Denies pruritus, bruises or rash. No new nevus. Denies history of contusions,
lacerations, burns or history of skin cancer.
OBJECTIVE:
Physical Exam
Vitals Signs: Temp (Axillary): 96.8 0F. BP-sitting L: 109/61 mmHg (BP cuff size: Regular). Pulse
Rate-Sitting: 92 bpm. (regular rhythm). RR: 18 per min. Height 5”1”, Weight: 123 lbs. BMI: 23.2
Kg/m2 (normal). Oxygen Saturation: 99 %. Pain Scale/Rate: 4/10.
General appearance: Patient in not apparent distress, speaks fluent, coherent, appears very
concerned about her clinical situation, but not anxious. Discomfort due to the pain is reflected in
his face and posture. Well hydrated, well nourished
Head: Normocephalic, symmetric head, no signs of trauma. Normal sinuses, maxillary and frontal
to palpation.
Neck: No visible mass. No lymphadenopathy noted. Thyroid in the middle, no palpable. No
palpable masses or tenderness, trachea is midline. No JVD.
Eyes: No strabismus observed during exploration, normal extraocular muscles function, no
discharge from the eyes, sclera is white, conjunctiva pink. PERRLA.
SOAP Note # 1 Dysmenorrhea
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Ears: Normal tragus and external canal. Meatus are normal. No swollen or reddened. Bilateral
tympanic membranes were intact and pearly gray with light reflex. No erythematous, scarred or
hemorrhage. No pus or serous exudate. No hearing loss on bilateral whisper test.
Nose: No external deformities of the nose. Nasal mucosa moist and pink with clear drainage,
septum midline. Nasal turbinate no erythematous, no swollen. No sinus tenderness.
Oral Cavity: Oral mucosa moist and pink. No lesions suggestive of malignancy or infections.
Normal gums and palate, no bleeding or hypertrophy. Good hygiene, no caries or abscess
detectable to single inspection, normal dentition.
Pharynx: Moist and pink, no presence of plaques or exudate. Absence of tonsils. No petechias,
no strawberry tongue. Normal pharynx and uvula to inspection, gag reflex presents and unaltered.
Lymph Nodes: No adenomegaly detected along the ganglion’s chains.
Chest: Symmetric chest wall, follow up the breading movement.
Lungs: Respirations are regular, equal, and unlabored with symmetrical chest expansion. No
cyanosis or nasal flaring observed. Normal breath sounds to palpation, unremarkable percussion.
Lung sounds clear to all lung fields. No wheezing, stridor, crackles or rhonchi noted.
Cardiovascular: Normal chest wall, absence of orthopnea, collateral circulation or edema on
lower extremities, no clubbing or cyanosis observed. No pericardial friction rub heard. Regular
rate and rhythm, heart sounds of S1 and S2, no bruits, murmurs found to auscultation, no extra
heart sounds, PMI at 5th intercostal space, midclavicular line. No pericardial friction rub heard.
No gallops, murmurs, or opening snaps. Carotid, apical, radial femoral and pedal pulses present
and strong, capillary refill 2 seconds.
Abdomen: Inspection: Symmetric, is watched flat, nondistended, no visible masses. No scars
SOAP Note # 1 Dysmenorrhea
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Auscultation: Bowel sound active in all 4 quadrants. No bruits. Palpation: soft, moderate pain when
palpating the lower abdomen (specifically the suprapubic area), no involuntary guarding or
rebound tenderness observed, no signs of peritoneal irritation, no palpable masses. No
hepatomegaly or splenomegaly. Percussion: Normal.
Genitourinary: Bimanual palpation does not reveal signs of enlarged kidneys. Costovertebral
angles do not reveal tenderness. No palpable or percussed bladder.
Gynecological: Patient positioned lying supine on the office examination table with the knees
flexed, and with the feet in supporting stirrups.
Inspection: Normal general appearance of the external genitalia, adequate hair
distribution. Scar of a previous medio-lateral right episiotomy. No presence of caruncle and other
findings to inspect the urethra. Symmetric vulva, without erythematous or edematous areas. No
discharge from vaginal orifice. Copious, fresh, red blood with small clots is observed flowing from
the vagina. No observable fissures or rashes. No perineal lesions.
Palpation: Moderate pain when palpating the suprapubic area 4/10, without peritoneal irritation
signs. No adnexal mass is palpated. No palpable Bartholin’s gland.
Speculum exam for Vagina and cervix.:
Vagina is observed with presence of rugae. Copious, fresh, red blood with small clots is observed
flowing through cervical orifice. No lesions observed.
Cervix is normal with observable clear mucus. No uterine prolapse is noted,
Bimanual exam: Unremarkable vagina, cervix, uterus and adnexal exam.No signs of pregnancy.
Pregnancy test done, negative result.
Breast: Inspection: Bilaterally symmetrical breast, no any changes in color, no irregularity
observed. No Ulceration of the skin or area of thickening noted. No observable convex skin
SOAP Note # 1 Dysmenorrhea
10
changes. No evidences of retraction phenomena.
Palpation: Right/Left breast, no palpable mass on any of the four quadrants. No enlargement of
axillary or supraclavicular nodes are palpated
Endocrine: She had no goiter, no ophthalmopathy, no hyperhidrosis, no tremor.
Hematologic: No adenomegaly found. No spleen/liver palpable.
Musculoskeletal: Normal gait. No muscular atrophies observed, no evident deformities, no
stiffness observed, range of motion within normal limited, normal joints. Fingers, feet and toes are
normal. Spine without deformity.
Neurologic: AAOx3. Keeps adequate communication ability, no concentration or attention deficit
noted during the exploration. Normal gait and balance observed. Sensation intact. Normal motor
activity. Deep tendon reflexes symmetrical and equal bilaterally. Normal function of all cranial
nerves (from I to XII). Bilateral UE/LE strength 5/5.
Psychiatric: Patient is euthymic, with normal level of mood , language and communication . The
affect was normal.
Integumentary: No observable diaphoresis. No discoloration presents, absence of cyanosis in
skin, lips, no suspicious nevi, good turgor on examination. Hair: Normal distribution according to
the gender and age. No hair loss in the lower extremities was observed.
Nails: Pink with normal appearance, absence of cyanosis in nails. No clubbing of the fingers. No
lesions.
11
SOAP Note # 1 Dysmenorrhea
ASSESSMENT:
Secondary Dysmenorrhea (N94.5)
On the basis of pathophysiology, dysmenorrhea is classified as primary dysmenorrhea (menstrual
pain without organic disease) or secondary dysmenorrhea (menstrual pain associated with
underlying pelvic pathology). The pain associated with dysmenorrhea is caused by hypersecretion
of prostaglandins and an increased uterine contractility.
Usually, for the diagnosis of dysmenorrhea, a focused clinical history and physical examination
are sufficient, however, pelvic ultrasound is considered very useful for ruling out secondary causes
such as endometriosis and adenomyosis. For the present discussed case, the presence of pain during
the menstrual period constitute the main clinical component to make a diagnosis of dysmenorrhea.
Despite there are some elements indicating the probability of a secondary dysmenorrhea, an
ultrasonography result is necessary to support this diagnosis and ruled out the primary form.
Differential diagnosis
Spontaneous abortion: either incomplete or complete abortion is ruled out. Based on meaning of
the term abortion (refers to a termination of a pregnancy either natural or induced), the patient
must be pregnant as an imperative requirement to be able to make the diagnosis of abortion. In the
discussed case, no pregnancy signs are found during the physical exam, also she has is a negative
pregnancy test, which does not support the diagnosis of abortion.
Ectopic pregnancy: Ruled out. Women with an ectopic pregnancy often complain of pelvic pain,
sometimes they have syncope, lightheadedness and vaginal bleeding. Not all ectopic
pregnancies present pain but just other symptoms related to a normal pregnancy as vague as nausea
and vomiting. In the discussed case, no pregnancy signs are found during the
12
SOAP Note # 1 Dysmenorrhea
physical exam, also the patient has is a negative pregnancy test. Even though, for a confirmatory
diagnosis of ectopic pregnancy, a transvaginal ultrasound imaging is necessary, the absence of
basic pregnancy finding allow to differentiate the dysmenorrhea from an ectopic pregnancy.
Ruptured ovarian cyst: Ruled out. It is characterized for acute onset of abdominal pain, typically
during strenuous physical activity, such as exercise or sexual intercourse. Other associated
symptoms include vaginal bleeding and weakness, even, syncope and circulatory collapse,
becoming in a medical emergency. In the physical exam it is possible to find from mild to severe
abdominal pain with guarding and peritoneal signs. An adnexal mass may be palpable. According
to the seriousness of this condition, orthostatic changes also could be consistent with copious
bleeding. In the discussed case, the pain and genital bleeding do not become so serious as to match
the described clinical manifestations.
Other differential diagnosis to take into consideration are: Pelvic inflammatory disease,
adenomyosis, pelvic congestion syndrome, endometriosis, ovarian torsion, uterine leiomyoma,
uterine polyps, IUD, Cervical stenosis.
PLAN:
Diagnostic tests ordered to support the diagnosis of secondary dysmenorrhea:
•
Pelvic and transvaginal Sonogram to rule out underlying pelvic pathologies.
•
Lab. studies: Urinalysis, CBC, ESR, CRP
Pharmacological treatment:
Non-steroidal anti-inflammatory drugs:
Ibuprofen tab 400 mg take 1 tab orally, preferably with any food, every 8 hours as
needed for pain.
Treatment will be completed according to tests results.
SOAP Note # 1 Dysmenorrhea
13
Non-pharmacological measures:
•
Application of warn compress
•
Physical exercises.
•
Keeps adequate genital hygiene.
•
Psychological support.
•
STD prevention
Patient education:
Some things that you should know about the Dysmenorrhea.
Dysmenorrhea is the medical term for menstrual cramps. Cramps are pain or discomfort in the lower
abdomen just during a menstrual period.
Dysmenorrhea can be either primary or secondary. Primary dysmenorrhea usually is not associated to any
subjacent condition. Secondary dysmenorrhea results from a specific disease or disorder.
How do they occur? Cramps are related to hormonal changes during your menstrual period. They are caused
by chemicals called prostaglandins. These chemicals cause the uterus to contract to pass menstrual fluid.
Women who have painful periods have larger amounts of prostaglandins or are more sensitive to these
chemicals.
How is it treated? The preferred treatment are the anti-inflammatory drugs such as ibuprofen or naproxen,
among other, to relieve the pain.
Another form of treatment is taking birth control pills. They decrease cramping by decreasing prostaglandin
production. If the pills relieve the pain, you may take them even if you do not need them for birth control.
Secondary dysmenorrhea may be treated with the same treatments, or the cause of the cramps may need to
be treated.
Consider that:
•
Ibuprofen is an anti-inflammatory and analgesic drug, which is going to help you to
relieve the pain. This drug should be taken with food to prevent the stomach upset.
SOAP Note # 1 Dysmenorrhea
14
•
Be compliant with the treatment. Call to the office if any adverse reactions is noted.
•
Resting in bed with a heating pad or hot water bottle on your abdomen may also relieve
the pain.
•
Avoid standing for a long time or walking on hard pavement.
•
Avoid foods and beverages that contain caffeine, such as coffee, tea, colas, and chocolate,
just before and during your period.
Follow-up/Referrals:
Follow-up: Next office visit will be when echography and lab results are available, to be
evaluated. Subsequent visits depend on symptoms progression.
Referrals: No necessary for now. Patient will be referred to gynecology depending on test
results and need for further evaluation.
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SOAP Note # 1 Dysmenorrhea
References
Armour, M., Parry, K., Manohar, N., Holmes, K., Ferfolja, T., Curry, C.,Smith, C. A. (2019). The
prevalence and academic impact of dysmenorrhea in 21,573 young women: A systematic
review and meta-analysis. J Womens Health (Larchmt), 28(8), 1161-1171. doi:
10.1089/jwh.2018.7615.
Armour, M., Smith, C. A., Steel, K. A., & Macmillan, F. (2019). The effectiveness of self-care and
lifestyle interventions in primary dysmenorrhea: a systematic review and meta- analysis.
BMC complementary and alternative medicine, 19(1), 22. doi:10.1186/s12906- 019-24338.
Bernardi, M., Lazzeri, L., Perelli, F., Reis, F. M., & Petraglia, F. (2017). Dysmenorrhea and related
disorders. F1000Research, 6, 1645. doi:10.12688/f1000research.11682.
De Sanctis, V., Soliman, A., Bernasconi, S., Bianchin, L., Bona, G., Bozzola, M., Perissinotto, E.
(2015). Primary Dysmenorrhea in Adolescents: Prevalence, Impact and Recent
Knowledge. Pediatr Endocrinol Rev, 13(2), 512-20.
Subasinghe, A. K., Happo, L., Jayasinghe, Y. L., Garland, S. M., Gorelik, A., Wark, J. D. (2015).
Prevalence and severity of dysmenorrhea, and management options reported by young
Australian women. Aust Fam Physician, 45(11), 829-834.

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