Women’s Health Soap Note

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.

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. Cranial Nerves: grossly intact. Sensation: grossly intact.

Skin: Inspection and Palpation: no rash, ulcer, induration, lesion, nodules, jaundice, or abnormal nevi and good turgor. Nails: normal.

Back: Thoracolumbar Appearance: normal curvature. Lumbar / Lumbosacral Spine normal extension and flexion and Motion Quality WNL, no spasms, and Palpation tenderness none.

Labs: Biopsy, Pap smear, Ultrasound Scan, Blood tests, Hysteroscopy, Culture test

ORDER SOAP Note Assignment HERE

Assessment 

Diagnosis: 

Post-menopausal atrophic vaginitis N95.2 – It is a vaginal disorder that usually happens after menopause that occurs when estrogen levels fall, causing the vaginal walls to become dry, thin, and inflamed. The patient has pain and light bleeding during sexual intercourse, vagina paleness, painful urination, incontinence and increased frequency of urination. Atrophic vaginitis symptoms are prevalent in women after menopause. The patient, however, denies any thin or colored discharge. 

Differentials: 

1. Uterine Cancer C55 – The patient is experiencing vaginal bleeding after menopause, pain during sexual intercourse and Abnormal Vaginal bleeding. However, the patient denies any watery or colored discharge. Lab tests do not show any abnormalities in the uterine to indicate uterine cancer.
2. Abnormal Uterine Bleeding N93.9- patient reports light bleeding after intercourse and is also on hormone treatment that may be causing her hormonal imbalance that can cause light bleeding. However, the patient denies prolonged and heavy bleeding, and lab tests rule out any uterus abnormalities.
3. Urinary Tract Infection (UTI) N39.0 – The patient reports pain and urgency during urination and incontinence. However, the patient denies tiredness, fever, nausea and blood in the urine.  

Plan 

• Topical applications such as moisturizers and lubricants for vaginal moisturization
• Hormone therapy, cream to be inserted via an applicator into the vagina. This cream is typically used daily for one to three weeks, followed by one to three times a week after the initial treatment.
• Kegel exercises recommended, 10 Squeezes three times a day

Patient Education 

• Educated the patient on lifestyle changes such as the benefits of wearing cotton and loose-fitting clothing that will improve air circulation around the genitals, making them a less ideal environment for bacteria to grow
• Educated the patient to avoid risky sexual activities that may put them at risk for contracting sexually transmitted diseases.
• Patient educated on the importance of sexual activity when they have vagina atrophy; lack of sexual activity can worsen the condition. Sex stimulates blood flow in the vagina and aids in producing fluids; therefore, sex keeps the vagina healthy.
• Patient educated on matters of sexual health and advised to seek medical help in case of any abnormalities they may experience.
• Patient educated on the side effects of medications especially on hormonal treatment
• Follow-up appointments after every three weeks are significant for the patient review

Rationale:

During menopause, estrogen levels in the body drop rapidly, resulting in vaginal dryness and thinness that may cause pain and light bleeding during intercourse. Hormone replacement therapy (Vaginal estrogen therapy) improves blood flow, thickness, and elasticity of the vaginal walls by applying estrogen directly to the vaginal area (Johansen et al., 2020). Vaginal estrogen therapy is an effective treatment for atrophic vaginitis and reduces vaginal dryness, itching, and pain during sexual intercourse caused by decreased estrogen levels (Mehta et al., 2021). At the same time, using Lubricants and moisturizers can improve comfort during sex as they add moisture and loosen the vagina.

It is essential that the patient make lifestyle changes such as wearing cotton and loose-fitting clothing and avoiding things that may irritate the vagina, such as perfumes and soaps. They must prioritize their sexual health and seek help for their symptoms or any unusual bleeding or discharge. The patient's urinary urge incontinence has been affecting her quality of life. Kegel muscles can help strengthen the pelvic floor muscles, which support the bladder, uterus, rectum and small intestine.

References

Johansen, N., Linden Hirschberg, A., & Moen, M. H. (2020). The role of testosterone in menopausal hormone treatment. What is the evidence? Acta Obstetricia et Gynecologica Scandinavica, 99(8), 966-969.

Mehta, J., Kling, J. M., & Manson, J. E. (2021). Current concepts include the risks, benefits, and treatment modalities of menopausal hormone therapy. Frontiers in Endocrinology, 12, 564781.

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