Write a brief SOAP note regarding this patient.

POST 1

Ellen is a 35-year-old female whose latest Pap smear result reports HSIL with positive HPV.  Ellen reports no h/o of STIs or previous abnormal Pap smear results. She had only two previous Pap tests 7 and 14 years ago.  Ellen is G1P0 with a TAB at age 25.  She and her partner are undecided whether they want to have children.  She has been monogamously married to a female partner for the last 5 years, but she considers herself bisexual and has previously engaged in sexual activities with males and females.  Ellen denies any significant medical history or current health problems. Her LMP was 5 days ago and her VS are WNL.  Her BMI is 24.7.  Her pregnancy test is negative.

Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

Subjective:

What other relevant questions should you ask regarding the HPI?

Any vaginal bleeding, discharge, pelvic pain, or other gynecologic symptoms? Denies any symptoms.

Date of last normal Pap smear? 7 years ago at age 28.

Any new sexual partners in the past year? No, monogamous with current partner for 5 years.

1. Has she ever been vaccinated against HPV? No.

What other medical history questions should you ask?

Any family history of cervical, ovarian, breast, colon or other cancers? No known family history.

1. Allergies to any medications? NKDA

Current medications including hormonal birth control? None.

Tobacco, alcohol, or drug use history? Denies.

• What other social history questions should you ask?
• Occupational exposures or high-risk sexual behaviors? None. Monogamous with current female partner. Prior sexual activity with both males and females.
• Support system – family or friends aware of diagnosis? Has not shared diagnosis with anyone yet.
• Concerns about how diagnosis may impact her life or relationships? Concerned about potential impact on fertility and current relationship.

Objective:

1. A&OX4

What other point of care testing (POCT) would you perform or order for this patient? Why?

• External genitalia: Normal female hair distribution, no lesions, masses, or discharge.
• Speculum exam: Vaginal mucosa pink and moist, no lesions or discharge. Cervix pink, no visible lesions, friable with contact bleeding. Os closed.
• Bimanual exam: No cervical motion tenderness, no adnexal masses or tenderness. Uterus normal size, shape, mobility.
• Wet prep: No clue cells, yeast, or trichomonads.

STI testing: GC/CT negative, RPR non-reactive, HIV neg.

1. UPT: Negative.

Assessment/ Diagnosis:

• What would be an appropriate diagnosis for her? Explain Ellen’s Pap smear results (pathophysiology) and the action(s) that will be taken next to follow up this abnormality, including patient education (explain the procedure to the patient).
• High grade squamous intraepithelial lesion (HSIL) of cervix with positive HPV
• The Pap smear shows high-grade precancerous changes (HSIL) caused by HPV infection. HPV is a very common STI that in some cases causes changes in cervical cells that can lead to cervical cancer if untreated. Further testing is needed to determine severity.

The next step is colposcopy, a procedure where a special microscope is used to closely examine the cervix, vagina and vulva. A biopsy of abnormal areas will likely be performed. This is the best way to diagnose precancerous changes or rule out cervical cancer.

1. For someone Ellen’s age (35), the 2018 USPSTF guidelines recommend either Pap testing every 3 years, high-risk HPV testing alone every 5 years, or co-testing with both Pap and HPV every 5 years through age 65. The 2021 ACS guidelines preferentially recommend primary HPV testing alone every 5 years from ages 25-65, with Pap testing every 3 years or co-testing every 5 years as acceptable alternatives.

Plan:

What will you prescribe for this patient? Why?

Schedule colposcopy with biopsy of visible lesions within the next 2-4 weeks. Explain that this exam is done in the office, takes about 10-15 minutes. May cause some discomfort, cramping or light bleeding. Advise to take 600-800mg ibuprofen 30-60 min beforehand if desired. No vaginal intercourse, douching, tampons for 1 week after.

What patient education is important to include for this patient?

1. Emphasize importance of timely colposcopy and biopsy to evaluate abnormal Pap smear findings (Krokidi et al., 2023).

Set expectations for colposcopy visit – in-office procedure taking 10-15 minutes, may cause mild discomfort or light bleeding.

• Discuss recommended cervical cancer screening schedule per 2021 ACS guidelines.
• Stress importance of routine screening for early detection and prevention, especially given her history of inadequate screening (Krokidi et al., 2023).
• Encourage making healthy lifestyle choices (no smoking, safer sex practices, healthy diet and exercise, stress management)
• Is there any education or advice you would give to Ellen regarding her current female partner?
• Reassure that female partner is at very low risk of contracting HPV or developing HPV-related cancers from sexual contact with Ellen.
• Encourage partner to continue routine GYN care and cervical cancer screening per guidelines for her age (Vorsters et al., 2022).

Acknowledge potential impact of diagnosis on their relationship and intimacy. Encourage open communication about any concerns.

1. Offer resources for support if needed (couples counseling, sexual health educators).

What pharmacological and non pharmacological education and advice can you give Ellen to help with her HSIL condition?

No specific medications to treat HSIL. Excisional procedures (LEEP, cone biopsy) may be recommended to remove abnormal tissue if colposcopy/biopsy confirms high-grade lesions.

1. Recommend HPV vaccination with 9-valent vaccine (Gardasil 9) if not previously vaccinated and no contraindications (Khieu & Butler, 2022).

Advise avoiding tobacco and nicotine products, as smoking is associated with higher risk of persistent HPV infection and progression of precancerous lesions.

Encourage safer sex practices (barrier protection) to reduce risk of acquiring new HPV infections (Pathak et al., 2022).

• Discuss role of healthy diet, regular physical activity, and stress reduction in supporting immune function.

If diagnosed with cervical cancer, may benefit from integrative therapies to manage treatment side effects and support quality of life.

POST 2 

DB SOAP NOTE

Subjective

1. CC: Annual physical exam

HPI: Denise, a 19-year-old female presents to the clinic for an annual physical exam.  She is G0P0 and presents with irregular menses only occurring every 3-4months apart within the past 2 years. She is sexually active and only uses condoms occasionally. She is not on any other birth control methods. She denies any significant medical or surgical health history and denies any other current health problems.  She has never had a Pap smear or any pelvic exam tests before today. Her pregnancy test is negative, and her vital signs are all WNL. The patient reported her first period to be at the age of 13 but does not remember her LMP. Patient denies a regular menstrual cycle, and stated that when they do occur, the menstrual lasts 3 to 4 days with heavy flow on second day. Patient denies clots with her menstrual. Patient report cramps during her menstrual. Patient deny having a boyfriend, but report having sex with 3 different men in the past 6 months. Patient does not remember using a condom in any of the encounters. Patient denies testing or diagnosis of STI in the past.

Medications: None provided

1. Allergies: No known medication allergies.

LMP: None provided.

Gyn/OB history: G0P0

PMH: None.

1. Chronic Illness/ Major trauma: None.

Family Hx: None provided.

Social Hx: Sexually active, with occasional use of condom. Has never been pregnant and have no child.

• ROS
• Constitutional: Denies fatigue, fever, or chills. Denies recent weight gains or losses of 20 pounds or greater, over the last 6 months.
• Eyes: Denies change in vision, loss of vision, blurred vision, or eyes pain.
  Ears: Denies difficulty hearing, hearing loss, or ear pain/earache
  Neck: Denies neck pain, or stiffness
  Respiratory: Denies shortness of breath, dyspnea, cough, hemoptysis, or wheezing
• Endocrine: Denies cold/hot intolerance, polyuria, polydipsia, polyphagia, or history of blood sugar instability. Denies swelling on the neck or nodules.
• Integumentary: Denies skin rash, itching, skin discoloration, abnormal skin, or recent skin injury. Denies breasts pain, discharge, or swelling.

Reproductive: Report irregular menses occurring every 3-4 months apart within the past 2 years. Report being sexually active and only using condom occasionally. Denies using any other birth control methods. Denies having done a pap smear or pelvic exam test. Denies vagina pain, itching, discharge, lesions, or burning.
Cardiovascular: Denies chest pain, palpitations, or dyspnea at rest
Gastrointestinal: Denies abdominal pain, rectal pain, nausea, vomiting, diarrhea, or constipation. Denies hemorrhoids, difficulty swallowing, or heartburn/acid reflux.
Urinary: Denies dysuria, hematuria, or urinary hesitancy.
Musculoskeletal: Denies muscle pain, joint pain, or back pain.
Neurological: Denies headaches, vertigo, lightheadedness, fainting, numbness, or tingling
Psychiatric: Denies change in mood, depression, sadness interfering with function, or anxiety

1. Objective Data

V/S: None provided.

• POCT: Pregnancy test- Qualitative urine human chorionic gonadotropin (HCG) test. Negative for pregnancy.
• System Exams
• General: Patient in no acute distress. Well nourished, developed, and groomed.
• Head: Normocephalic, full hair, and atraumatic

Eyes: White sclerae. Clear conjunctivae and lashes. Pupils equal round reactive to light and accommodation (PERRLA). Intact extraocular movements.

1. ENT (ear, nose, mouth, and throat): External ear canals clear without cerumen. Tympanic membrane clear, pearly gray with good light reflex bilaterally. Ears intact to whispers. Nares patent and mucosa pink, moist, and intact. Mouth, lips, tongue, and gums intact with no lesions. Good dentition. Hard and soft palates intact. Tongue and uvula midline.

Neck: Supple. No thyromegaly, or lymphadenopathy. No jugular vein distention.

• Respiratory: Unlabored breathing. Chest rise is equal and symmetric. No use of accessory muscles to breathe. Lungs clear to auscultation bilaterally. No rales, wheezes, or rhonchi.
• Cardiovascular: S1 S2 without murmurs, rubs, or gallops
• Gastrointestinal: Normoactive bowel sounds. Abdomen soft, and nontender to palpation. No masses, no hepatosplenomegaly.
• Integumentary: Skin warm, dry, and intact. No rashes, lesions, masses, or discoloration. No abnormality to fingers nails or toenails. Breasts with no dimple, discharge, mass, or discoloration.
• Extremities: No edema of the extremities. Pulse +2 bilateral radial and pedal. No cyanosis or clubbing.
• Musculoskeletal: Steady gait. Full range of motion in all joints. Muscle strength and tone 5/5 in all groups. Equal arm swing. Normal spinal curvature.

Neuro: Alert to self, place, and time. Recent and remote memory intact. Cranial nerves intact II- XII. Sensation intact to light and touch.

Psychiatric: Mood and affect appropriate during visit. Judgment/insight intact.

Reproductive: No suprapubic tenderness or bulges. No lesions, rashes, mass, or swelling.

Assessment/ Diagnosis

Abnormal Uterine Bleeding, Unspecified. ICD-10-CM N93.9.

Abnormal uterine bleeding diagnosis is used to refer to menstrual bleeding of abnormal quality, duration, or schedule. The patient in this case has an irregular bleeding schedule that occurs every 3 to 4 months, instead of regularly every month. The patient denies any past medical history, and the use of any other contraceptive expect occasional use of condom. Patient does not present with any other clinical manifestation. The goal of treatment is to identify any underlying cause of the abnormal bleeding schedule and to establish a regular bleeding pattern. The irregular bleeding may be due to hormonal imbalance (estrogen and progesterone) that may be caused by stress, excessive physical exercise, rapid weight loss or gain, thyroid disorders, or polycystic ovarian syndrome. Therefore, the annual physical exam and bloodwork would provide an idea of the patient’s health status.

DDX:

Hypothyroidism, Unspecified. ICD-10-CM E03.9.

Hypothyroidism is a condition in which the serum thyroid stimulating hormone (TSH) is elevated and the serum free thyroxine (T4) is low. Clinical manifestations include fatigue, cold intolerance, weight gain, constipation, dry skin, menstrual irregularity, goiter, or bradycardia. Treatment includes thyroid hormone therapy. Positive pertinent: Patient present with irregular menstrual. Negative pertinent: Patient denies fatigue, cold intolerance, weight loss, constipation, or dry skin. The thyroid panel included in the annual labs would assist in determining the patient’s thyroid status.

Other sex counseling. ICD-10-CM Z70.8.

The patient needs counseling and education regarding sexually transmitted infections (STI). The patient reports that she is sexually active but only uses a condom occasionally. This practice puts the patient at a higher risk for contracting sexually transmitted infection. Besides the many effects of STIs (genital herpes, syphilis, chlamydia, and gonorrhea), if left untreated can affect the reproductive system and the menstrual cycle resulting in irregular menstruation. STI panel included in the annual labs would help rule out if any untreated STI can be the cause of irregular menstruation.

Plan

Diagnostic tests:
Annual women labs: CMP, WBC, A1c, Thyroid panel, Lipid panel, Vitamin D, and STI panel.

Treatment: Start patient on birth control, and counsel on safe sex.

Medication: DMPA injection (Depo-Provera) 104mg/ml subcutaneous every 12 weeks.

Referrals: None

Education:

It is important to schedule injections every 12 weeks to maintain the contraceptive effectiveness.

Ovulation and conception may take longer to return after depo Provera is stopped.

Patients may experience irregular periods, spotting, or amenorrhea while on Depo Provera.

Long term use may cause bone mineral density loss.

Patients may experience headaches, weight gain, changes in appetite, or mood changes.

Depo Provera does not protect against STIs.

Practices safe sex by using protection always.

Use condom consistently to help prevent infection with STIs.

Health Maintenance: Immunization offered for flu shot, Covid -19. Screen for chlamydia, syphilis, gonorrhea, HIV, and Hepatitis C. Recommend routine dental and eye checkup.

Follow up: RTC in 2 weeks for lab results review.

Prompt Questions

(You can include answers here that is asked in the prompt)

POCT– Urine pregnancy HCG test.

The pap smear test is a screening test for cervical cancer. According to U.S. Preventive Services Task Force (USPSTF), pap smear test is recommended for women aged 21 to 65. This patient being 19 years old, no pap smear test will be performed in this visit (National Cancer Institute, 2023).

Appropriate diagnosis: Abnormal Uterine Bleeding, Unspecified. ICD-10-CM N93.9.

This is the appropriate diagnosis because the patient chief complain was routine physical exams, but in the process of the assessment other abnormal findings were determine (irregular menstrual, and occasional unprotected sex).

Differential diagnosis:

Hypothyroidism, Unspecified. ICD-10-CM E03.9.

Other sex counseling. ICD-10-CM Z70.8.

Prescription: DMPA injection (Depo-Provera)