DN, 25 y/o F

advertisement
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
Download