Vaginal SOAP Note DN, 25 y/o F 8/22/12, 1130am Shinglehouse Family Practice Candy Hull PA-S, Eric Schreiber, PA-C CHIEF COMPLAINT: Here for annual exam, unable to feel Mirena strings and would like to have them checked. S: 25 y/o G0P0 here for annual exam. Menarche 13 y/o, lasts 3 days q 28 days regularly, light flow. Regular menses without intracycle spotting. Mirena IUD for contraception protection in place since 2009, only problem is that she can no longer feel strings. Has not experienced polymenorrhea, dysmenorrhea, metromenorrhagia, oligomenorrhea. Been in a monogamous heterosexual relationship for 3 years. No current sexual concerns or problems. Had had 3 sexual partners in lifetime and has used a condom until last 2 years with current boyfriend. Douches 1ce/month after menses, does monthly self breast exams. Last pap 1 year ago, no hx of abnormal pap smears, no hx STI. Exercises regularly 5x/wk, well-balanced diet, wears seat belt. HPI: Unable to feel Mirena strings for past 2 months. Denies any pain or sexual discomfort complaints from boyfriend. LMP 8/7/12. Denies any change in bladder function, dysuria, nocturia, increased frequency, or change in bowel habits. No hx UTI, kidney or gallstones, recurrent infections, or incontinence. No other concerns voiced by patient. Medications: Protonix 40 mg qd Tylenol 500mg bid PRN Allergies: Latex (rash, edema) PMH: Has not tried any other birth control method previously. No prior hospitalizations, trauma, or surgeries. Immunizations up to date, gets influenza vaccine yearly. No known chronic diseases. 0/10 pain FH: 18 y/o sister without chronic disease. 22y/o brother with asthma & seasonal allergies. Parents both alive (father – 50 y/o, mother – 49 y/o) without chronic disease. PGM died 80 y/o resp failure. PGF 80 y/o alive in nursing home with HTN & CAD. MGM alive 75 y/o with DJD/arthritis. MGF alive 78 y/o without chronic disease. Denies any history of CA, stroke, PAD, DM, bleeding disorders, tuberculosis, epilepsy, mental illness. SH: Lives with boyfriend in apartment by themselves, family very close and they all live in the area. She is very active; enjoys anything outdoors (hiking, camping, four wheel riding). Denies smoking, drinking, recreational drugs. Works as grocery store clerk since 2010. ROS General: denies any recent weight changes, weakness, fever, night sweats Skin: denies any acne, eczema, psoriasis HEENT: denies any recent trauma, loss of consciousness, headaches, dizziness, vision changes, watery eyes, tinnitus, hearing loss, recurrent ear infections, recurrent sinusitis, allergies, rhinorrhea, epistaxis, sinus tenderness, sore throat CV: no history of AAA, murmur, DOE, edema, palpitations, chest pain Respiratory: denies ever having episode of SOB, asthma, sleep apnea, wheezing, cough, snoring, pneumonia, anaphylactic reaction GI: Hx of GERD. Denies any constipation, abdominal pain, N/V/D. GU: denies any enuresis, burning, pain Vaginal: denies any discharge, tenderness, masses Vascular: denies any peripheral edema, anemia, bleeding problems, bruising, petechiae MS: denies any fractures, muscle aches, pain, ROM limitations Neuro: denies any hx of hyperactivity/ADHD, autism, developmental delays Endocrine: denies any heat/cold intolerance, diaphoresis, polyuria, polydipsia, polyphagia Psych: denies any anxiety, mood swings, depression, schizophrenia ID: no known recent exposures/travel O: Vitals Height: 5 ft 8 in/173 cm, Weight: 152 lbs 0 oz / 69 kg, BSA: 1.82 m2, BMI: 23.1 kg/m2 T: 97.9 F / 36.6 C (Tympanic), Pulse: 90, RR: 18, BP: 112/70 (Sitting, Left Arm) General appearance: WDWN, NAD Skin: No café au lait spots, dry patches, ecchymosis, hemangiomata, nevi, rash, acne HEENT: Normocephalic/atraumatic, no conjunctivitis, discharge, nystagmus, strabismus, AV nicking. TM intact, no bulging, tenderness, erythema, fluid, cerumen obstruction, scarring. Nostrils patent, no drainage or obstruction. Oral mucous membranes moist without ulceration, lesions, white lacy patterns or patches. Oropharynx and tonsils without erythema, exudate, postnasal drainage, thrush, hypertrophy, peritonsillar abscess. Neck supple without adenopathy or tenderness. Thyroid not enlarged, firm, or nodular CV: No chest wall deformities visualized. RRR, S1 and S2. No murmur, S3 or S4, rub or click. PMI 5th ICS midclavicular line Respiratory: Breathing unlabored, no retractions or accessory muscle use. No crackles, wheezing, rhonchi on auscultation. No dullness or hyperresonance to percussion. Tactile fremitus present, not decreased GI: Negative for tenderness or distension. Bowel sounds heard all 4 quadrants without bruit. Abdomen soft without mass, rigidity, organomegaly, hernia. Tympanic percussion heard over epigastric region, dull percussion heard over liver GU: No rashes, ulcers, scars, nodules, induration, discharge, or mass Breasts: no masses, adenopathy, rashes, dimpling Pelvic: External Genitalia: shaven without lice or lesions, labia majora and minora not tender or enlarged. Bartholins and Skenes glands not enlarged, erythemateous or tender. Introitus patent, perineum without abscess or swelling. No masses, lesions, excoriation, or discharge noted. Internal Genitalia: vagina pink coloration without rugae or decreased musculature tone. No cystocele, rectocele, discharge noted. Cervix –os visualized with Mirena strings in place. No lesions, discharge, CMT. Uterus without masses or tenderness. Adnexae bilaterally nontender, no masses. Vascular: Symmetrical posterior tibial and dorsalis pedis pulses (2+, 0-4), radial pulse 2+ bilat MS: Negative for scoliosis, asymmetry, kyphosis, crepitus, deformity, mass, tenderness. No decreased ROM. 100% full flexion, extension, lateral bending, rotation. Heel-toe walk without ataxia Neuro: Motor grossly intact, sensory grossly intact Endocrine: No diaphoresis Psych: No sign of depression, acute stress, anxiety, ADHD/OCH A: Well women exam Undesired fertility P: Pap smear Consent obtained. Sterile field prepared. Lube applied to lighted vaginal speculum and inserted into vagina. Vaginal walls were visualized and speculum was opened. Cervix and Mirena strings were visualized. An Aylesbury spatula was used to obtain a specimen from the os and an a brush was used to obtain a sample from the center of the os. Ovaries were palpated and nontender. Mirena was left in place. Patient tolerated procedure well with minimal discomfort. Was told to take Tylenol 500mg for any discomfort. RTC 1 year for annual exam. PRN if needed Education/Guidance IUD expectations Human sexuality Nutrition & Fitness Candy Hull Candy Hull, PA-S 8/22/12, 1230