response s

I NEED A RESPONSE FOR THE 2 SOAP NOTES (1 IS BELOW THE OTHER ONE IS ATTACHED). It is not another soap note, it is a response to the peer who did the soap notePATIENT INFORMATIONName: Mrs.: M.B.Age: 44-year-oldSex: FemaleSource: PatientAllergies: NoneCurrent Medications: Ibuprofen 400 mg, I tab when feels painPMH: Denies any disease.Immunizations: Influenza this September 2019Surgical History: NoneFamily History: Father- alive 66 years old, healthyMother-alive, 67 years old, AsthmaDaughter-alive, 15 years old, healthySocial Hx: Smoking history, 2 packs a day, occasional alcoholic beverage consumption on social celebrations.SUBJECTIVE:Chief complain: “I have painful periods and pain following sexual intercourse”.Symptom analysis/HPI:The patient is 44 years old female hispanic, who complaining of painful periods and she also refers pain following sexual intercourse. She experiences occasional heavy menstrual periods and bleeding between periods. The symptoms starting 4 months ago, now are worse. The patient denies chest pain, palpitation, shortness of breath, nausea or vomiting. Denies any past medical condition.ROS:CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss.HEENT: HEAD: Denies any head injury or change in LOC. Eyes: Denies any changes invision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing ordrainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain,hoarseness, difficulty swallowing.Respiratory: Patient denies shortness of breath, cough or hemoptysis.Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnaldyspnea.Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea,vomiting or diarrhea.Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Deniesdifficulty starting/stopping stream of urine or incontinence.MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snappingsound.Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.NEUROLOGIC: Denies headache, dizziness or changes in LOC. Denies history oftremors or seizures.Objective DataCONSTITUTIONAL:Vital signs:Temperature: 97 °F,Pulse: 66 x min.BP: 130/80 mmhg.RR 18 x min.PO2-98 % on room air.Ht- 5’5”Wt 162 pnsBMI 22.5 m2.Report pain 0/10.General appearance: The patient is alert and oriented x 3. No acute distress noted.HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses notenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eyemovements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema,or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillarysinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions.Lids non-remarkable and appropriate for race.Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroidswelling or masses.Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillaryrefill < 2 sec.Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whisperedpectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally onauscultation.Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present inall four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding,no rebound no distention or organomegaly noted on palpationMusculoskeletal: No pain to palpation. Active and passive ROM within normal limits, nostiffness.Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.Gynecologic exam: During a pelvic exam, no abnormalities such as cysts in thereproductive organs or scars behind the uterus were found.NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time.Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.Assessment:ICD 10: N80.9; Endometriosis based in the patient’s symptoms. I order some tests to ruleout other conditions. Chronic inflammatory condition defined by endometrial stroma and glandsfound outside of the uterine cavity. The most common sites affected are the pelvic peritoneumand ovaries. May present incidentally in asymptomatic patients, or more commonly in women ofreproductive age who complain of chronic pelvic pain and/or subfertility. Clinical suspicion isgenerally sufficient to initiate therapy, but the diagnosis can only be confirmed by directvisualization and focused biopsies during laparoscopy.ICD 10: Z12.4; Encounter for screening for malignant neoplasm of cervix.Differential diagnosis:ICD 10: N80.0; Adenomyosis; Symptoms may be identical to those of endometriosis.Preoperative MRI findings may show diffuse or focal widening of the junctional zone (innermyometrium), islands of endometrial tissue or cystic dilation of glands or hemorrhage, linearstriations radiating out from the endometrium into the myometrium, mass within themyometrium (adenomyoma). Laparoscopy may reveal a normal pelvis or concurrentendometriosis. Histopathologic evaluation of the uterus after hysterectomy shows endometrialglands/stroma in the myometrium.ICD 10: N30.10; Interstitial cystitis; Symptoms primarily localized to the bladder, such asurinary frequency and urgency. Patients complain of pain with a full bladder that is relieved uponvoiding. Diffuse chronic pain and dyspareunia are common and often indistinguishable fromendometriosis.ICD 10: Ovarian cyst (benign); May be asymptomatic with an incidental pelvic mass orpresent with acute rather than chronic pain, such as in the case of hemorrhagic cysts.PlanLaboratory Exam:Ultrasound. To identify cysts associated with endometriosis (endometriomas).Magnetic resonance imaging (MRI). To obtain a detailed information about the locationand size of endometrial implants.Pharmacological treatment:Ibuprofen (500 mg) 1 tablet 4 times a day if you feel painElagolix (Orilissa) – 1 tablet taken twice dailyNon-Pharmacologic treatment:If the pain persists you can try measures at home to relieve the discomfort taking warmbaths and a heating pad, helping relax pelvic muscles and reducing cramping and pain.Follow-ups/ReferralsFollow up: in 2 weeks to evaluate current treatment.Referrals No needed at this time.

 

Do you need a similar assignment done for you from scratch? We have qualified writers to help you. We assure you an A+ quality paper that is free from plagiarism. Order now for an Amazing Discount!
Use Discount Code "Newclient" for a 15% Discount!

NB: We do not resell papers. Upon ordering, we do an original paper exclusively for you.