Women’s Health Soap Note # 2 Bay Path University

Women’s Health Soap Note # 2 Bay Path University

Course

< Supervisor's Name>

07/29/2022

Women’s Health Soap Note # 2

PATIENT INITIALS: E.M. AGE: 62 Years, GENDER: Female RACE: African-American

Subjective

CC: Discomfort with sexual intercourse and light bleeding.

 HPI: E.M. is a 62-year-old black American who presents to the clinic with concerns about pain during sexual intercourse. She reports that this is the fourth time it has happened in two months and was embarrassed to come to the clinic and is now avoiding intercourse. Her menopause was late and happened when she was 55. Post-menopausal symptoms continued after 55, and she would have vaginal dryness, hot flashes and thinning. Her previous OBGYN recommended estrogen replacement therapy to relieve the problems. She reports that the hormone treatment worked. The patient says that she is also experiencing urgency and burning with urination. The patient also reports that over the last two months, she has been experiencing urinary incontinence, which is starting to affect her quality of life. The patient also says that she thinks her vagina is paler than usual.

Past Medical Hx

Hospitalization: The patient has had one hospital admission in the last year for food poisoning.

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Surgery: Myomectomy when she was 45

Family Hx

The patient is married and has two daughters and one son. Her daughter, who is now 30 years was diagnosed with fibroids at 24 years. The patient's mother had a hysterectomy at 40 years. Her sister died at 48 from ovarian cancer. 

Social Hx

The patient was born and raised in Mississippi but moved to Massachusetts when she was married. She has three children and works as a real estate agent. She is a social and outgoing person and occasionally enjoys alcohol.

Allergies

No known food, environmental or medication allergy.

Medications

Patient on tramadol 100 mg orally once a day 

Objective (PE)

VS: T- 97.6° F, BP- 134 / 87 mmHg, RR- 15 bpm, HR- 70 bpm, SPO2- 97%

Constitutional: General Appearance: Appropriate. Level of Distress: NAD. Ambulation: ambulating normally.

Psychiatric: Insight: Good judgement. Mental Status: normal mood and affect and active and alert. Good orientation: to time, place, and person.

Head: Head: normocephalic and atraumatic.

Eyes: Lids and Conjunctivae: no discharge or pallor and non-injected. Pupils: PERRLA. Corneas: grossly intact. Sclerae: non-icteric. Vision: peripheral vision grossly intact and acuity grossly intact.

ENMT: Ears: no lesions on the external ear, EACs clear, TMs clear, and TM mobility normal. Hearing: no hearing loss. Nose: no lesions on external nose, septal deviation, sinus tenderness, or nasal discharge and nares patent and nasal passages clear. Oropharynx: no erythema or exudates and moist mucous membranes and tonsils not enlarged.

Neck: Neck: supple, FROM, trachea midline, and no masses. Thyroid: no enlargement or nodules and non-tender.

Lungs: Respiratory effort: no dyspnea. Percussion: no dullness, flatness, or hyper resonance. Auscultation: no wheezing, rales/crackles, or rhonchi, and breath sounds normal, good air movement, and CTA except as noted.

Cardiovascular: Apical Impulse: not displaced. Heart Auscultation: regular S1 and S2; no murmurs, rubs, or gallops; and RRR. Neck vessels: no carotid bruits. Pulses including femoral / pedal: normal throughout.

Abdomen: Bowel Sounds: normal. Inspection and Palpation: no tenderness, guarding, masses, rebound tenderness, or CVA tenderness and soft and non-distended. Liver: non-tender and no hepatomegaly. Spleen: non-tender and no splenomegaly.

Musculoskeletal: Motor Strength and Tone: normal tone and motor strength. Joints, Bones, and Muscles: no contractures, malalignment, tenderness, or bony abnormalities and normal movement of all extremities. Extremities: no cyanosis, oedema, varicosities, or palpable cord.

Neurologic: Gait and Station: normal gait and station. Crani