Post-Menopausia bleeding thesis
SOAP NOTE: Post-Menopausia bleeding.
MRU
MSN6050 ADVANCE PRACTICE IN PRIMARY CARE- WOMEN’S HEALTH.
PATIENT INFORMATION
Name: Ms. TM
Age: 57 years old
Race: Hispanic
Gender at birth: Female.
Gender identity: Female.
Source: Patient.
Allergies: Penicillin.
Current medications: Lisinopril 10 mg tab, 1tab daily.
Atorvastatin 20 mg tab, 1 tab daily.
Insurance: PPO.
PMH: Denies.
Surgical History: Appendectomy at 13 y/o.
Immunizations: Influenza. December 2020.
Preventive care: Last PAP smear August 2018. Normal.
Mammogram: Normal. BIRADS 0
Exposure: No knows HIV exposure during the last year. No blood transfusions or received other blood components or tissues.
Environmental exposure was unknown to asbestos, radiations or other chemical substances. No exposure to the sunlight during day activities for long periods of time.
Family History: Father deceased CAD.
Mother alive: 85 y/o, HTN.
Social History: Patient is heterosexual, single, and lives with her husband, roommate, and has a daughter 35 y/o. No domestic violence suspected or negligent behaviors. Client denies using drugs she said that she drinks alcohol only socially. Patient denies smoking tobacco or marihuana.
Nutrition history: She reports a healthy diet, low in sugar and salt.
Chief complaint: “I have my period again”
History of present illness: The patient is a Hispanic female, 57 y/o, G1T1P0A0L1, that
comes to the office staying “I have my period again”. She reports that she has watery, bloody
vaginal discharge for 2 weeks. This never happen before. Her last menstrual period was around 8
years ago. The client denied having had vaginal discharge. She is divorced for three years ago
and she did not have sexual activity since that time. The las pap test was in 2018, and the result
comeback negative. She denies history of sexual assault or trauma, also reports mild
discomfort on pelvic area, no fever or chills. There is not change on her appetite, no weight loss, malaise or weakness.
No previous hospitalizations or invasive procedures in the past twelve months. No history of
mental illness. No physical trauma or falls reported during the last year.
HPI- Women’s Health part:
Menstrual history: Monthly, denies clot or bleeding.
Age of Menarche: 11 yo
Last menstrual period: 2013.
Bleeding pattern. Reports vaginal bleeding during the last 2 weeks.
Associated pain (dysmenorrhea): N/A.
Break through bleeding: N/A.
Length of cycle: N/A.
Average number of days of menses: N/A
Pre-menopause/menopause: Yes. Vasomotor symptoms: Yes.
Hormone replacement therapy: No.
Condom use: No.
Vaginal douches: No.
Level of satisfaction with sexual activity: good
History of sexual assault: no
Contraceptive use: N/A.
Previous method, including complications, reason discontinued: Same method.
Cervical and vaginal cytology: 2013. Normal
Most recent PAP Smear: Normal.
History of abnormal PAP Smear? Denies.
History of sexually transmitted infections: She denies having had any sexually transmitted disease.
Vaginitis: Denies. History of Pelvic inflammatory disease? Denies.
Any difficulty conceiving in the past? Denies.
Sexually active: Yes, she has a fixed partner for the last 35 years.
History of sexual abuse or sexual assault: Denies.
Obstetric history:
G 1
T 1
P 0
A 0
L 1
Describe any maternal, fetal, or neonatal complications? Denies.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Denies fever, chills or malaise. Denies low energy in the past two weeks as identified in the PHQ-9 questionnaire. Denies weight loss, change of appetite.
NEUROLOGIC: Denies headache, changes in LOC, history of tremors or seizures, weakness, numbness, dizziness, headaches. Denies trouble walking, syncope, sleep disorder, memory problems.
PSYCHIATRIC: Mood was euthymic, not feeling restless or anxiety. No feeling hopelessness or depressed. No sleep disturbances, trouble falling or staying asleep. Normal enjoyment of activities. Not easily distracted and no change in thought patterns.
HEENT: Head: Denies head injuries, or change on LOC. Eyes: No irritation, no drainage, no dry eyes, no pain on eyes’ structures or retro-orbital, no vision changes, no diplopia, or blurred vision. Ears: Denies loss of hearing, no ear pain, no drainage, no sensation of ears feeling full, no ear ringing, or ears’ trauma. Nose: Denies nasal congestion, no nasal drainage, no nosebleeds, and normal smell sense. Throat/Mouth: Denies sore throat, no hoarseness, no difficulty swallowing, or postnasal drip. No mouth sore, no thrush, no bleeding gums, no lips sore, no teeth problems.
NECK: Denies neck pain, no masses, no nodules, no history of thyroid abnormality.
RESPIRATORY: Denies chest congestion or wheezing, coughing, shortness of breath.
CHEST/ BREAST: Denies chest abnormalities, no breast lumps, no nodules, no nipple drainage, or nipple retraction.
CARDIOVASCULAR: Denies chest pain, palpitations. No orthopnea, or paroxysmal nocturnal dyspnea. Denies edema, irregular heartbeat, low or high blood pressure, poor circulation, cold extremity, or claudication.
GASTROINTESTINAL: Normal appetite as identified in the PHQ-9 questionnaire. No dysphagia or heartburn. No nausea, vomiting or abdominal pain. No hematochezia. No diarrhea or constipation.
GENITOURINARY: Denies dysuria, frequency, urgency, hesitancy, incontinence, nocturia, or
hematuria. No history of UTI and kidney infections
EXTERNAL GENITALS: The patient reports watery, bloody vaginal discharge for 2 weeks
and mild discomfort over the pelvic area. No history of STD.
MUSCULOSKELETAL: Denies fall, muscle or joint pain. Denies hearing a clicking or snapping sound. Denies numbness, hemiplegia o paresthesia, muscular atrophy or weakness. Denies limited range of mobility, joint pain or limited ROM.
HEMATOLOGIC: Denies easy bruising, loss of hair, heat/cold intolerance, changes in nails, enlarged glands, prolonged bleeding, increased thirst, or hunger.
SKIN: Denies skin rash, no wound, no change on skin color or texture, no change in a mole, no unusual growth, no dry skin, no itching, or jaundice. Hair: Denies hair loss, no hair abnormalities. Nails: Denies nails abnormalities, no discoloration, no clubbing, no cyanosis, or longitudinal ridges.
