Name: <\/strong>Mrs.: M.B.<\/p>\n Age:<\/strong> 44-year-old<\/p>\n Sex: <\/strong>Female<\/p>\n Source:<\/strong> Patient<\/p>\n Allergies: <\/strong>None<\/p>\n Current Medications:<\/strong> Ibuprofen 400 mg, I tab when feels pain<\/p>\n PMH:<\/strong> Denies any disease.<\/p>\n Immunizations: <\/strong>Influenza this September 2019<\/p>\n Surgical History:<\/strong> None<\/p>\n Family History:<\/strong> Father- alive 66 years old, healthy<\/p>\n Mother-alive, 67 years old, Asthma<\/p>\n Daughter-alive, 15 years old, healthy<\/p>\n Social Hx: <\/strong>Smoking history, 2 packs a day, occasional alcoholic beverage consumption on social celebrations.<\/p>\n SUBJECTIVE:<\/strong><\/p>\n Chief complain: <\/strong>\u201cI have painful periods and pain following sexual intercourse\u201d.<\/p>\n Symptom analysis\/HPI:<\/strong><\/p>\n 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.<\/p>\n ROS:<\/strong><\/p>\n CONSTITUTIONAL:<\/strong> Denies fever or chills. Denies weakness or weight loss.<\/p>\n HEENT: <\/strong>HEAD: Denies any head injury or change in LOC. Eyes: Denies any changes in<\/p>\n vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or<\/p>\n drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain,<\/p>\n hoarseness, difficulty swallowing.<\/p>\n Respiratory:<\/strong> Patient denies shortness of breath, cough or hemoptysis.<\/p>\n Cardiovascular:<\/strong> No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal<\/p>\n dyspnea.<\/p>\n Gastrointestinal: <\/strong>Denies abdominal pain or discomfort. Denies flatulence, nausea,<\/p>\n vomiting or diarrhea.<\/p>\n Genitourinary: <\/strong>Denies hematuria, dysuria or change in urinary frequency. Denies<\/p>\n difficulty starting\/stopping stream of urine or incontinence.<\/p>\n MUSCULOSKELETAL:<\/strong> Denies falls or pain. Denies hearing a clicking or snapping<\/p>\n sound.<\/p>\n Skin: <\/strong>No change of coloration such as cyanosis or jaundice, no rashes or pruritus.<\/p>\n NEUROLOGIC:<\/strong> Denies headache, dizziness or changes in LOC. Denies history of<\/p>\n tremors or seizures.<\/p>\n Objective Data<\/strong><\/p>\n CONSTITUTIONAL:<\/strong><\/p>\n Vital signs:<\/strong><\/p>\n Temperature: 97 \u00b0F,<\/p>\n Pulse: 66 x min.<\/p>\n BP: 130\/80 mmhg.<\/p>\n RR 18 x min.<\/p>\n PO2-98 % on room air.<\/p>\n Ht- 5\u20195\u201d<\/p>\n Wt 162 pns<\/p>\n BMI 22.5 m2.<\/p>\n Report pain 0\/10.<\/p>\n General appearance:<\/strong> The patient is alert and oriented x 3. No acute distress noted.<\/p>\n HEENT: <\/strong>Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no<\/p>\n tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye<\/p>\n movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema,<\/p>\n or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary<\/p>\n sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions.<\/p>\n Lids non-remarkable and appropriate for race.<\/p>\n Neck:<\/strong> supple without cervical lymphadenopathy, no jugular vein distention, no thyroid<\/p>\n swelling or masses.<\/p>\n Cardiovascular:<\/strong> S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary<\/p>\n refill < 2 sec.<\/p>\n Respiratory:<\/strong> No dyspnea or use of accessory muscles observed. No egophony, whispered<\/p>\n pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on<\/p>\n auscultation.<\/p>\n Gastrointestinal: <\/strong>No mass or hernia observed. Upon auscultation, bowel sounds present in<\/p>\n all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding,<\/p>\n no rebound no distention or organomegaly noted on palpation<\/p>\n Musculoskeletal:<\/strong> No pain to palpation. Active and passive ROM within normal limits, no<\/p>\n stiffness.<\/p>\n Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.<\/p>\n Gynecologic exam: <\/strong>During a pelvic exam, no abnormalities such as cysts in the<\/p>\n reproductive organs or scars behind the uterus were found.<\/p>\n NEUROLOGIC:<\/strong> Alert, CNII-XII grossly intact, oriented to person, place, and time.<\/p>\n Sensation intact to bilateral upper and lower extremities. Bilateral UE\/LE strength 5\/5.<\/p>\n Assessment:<\/strong><\/p>\n ICD 10: N80.9; Endometriosis based in the patient\u2019s symptoms<\/strong>. I order some tests to rule<\/p>\n out other conditions. Chronic inflammatory condition defined by endometrial stroma and glands<\/p>\n found outside of the uterine cavity. The most common sites affected are the pelvic peritoneum<\/p>\n and ovaries. May present incidentally in asymptomatic patients, or more commonly in women of<\/p>\n reproductive age who complain of chronic pelvic pain and\/or subfertility. Clinical suspicion is<\/p>\n generally sufficient to initiate therapy, but the diagnosis can only be confirmed by direct<\/p>\n visualization and focused biopsies during laparoscopy.<\/p>\n ICD 10: Z12.4; Encounter for screening for malignant neoplasm of cervix.<\/strong><\/p>\n Differential diagnosis:<\/strong><\/p>\n ICD 10: N80.0; Adenomyosis;<\/strong> Symptoms may be identical to those of endometriosis.<\/p>\n Preoperative MRI findings may show diffuse or focal widening of the junctional zone (inner<\/p>\n myometrium), islands of endometrial tissue or cystic dilation of glands or hemorrhage, linear<\/p>\n striations radiating out from the endometrium into the myometrium, mass within the<\/p>\n myometrium (adenomyoma). Laparoscopy may reveal a normal pelvis or concurrent<\/p>\n endometriosis. Histopathologic evaluation of the uterus after hysterectomy shows endometrial<\/p>\n glands\/stroma in the myometrium.<\/p>\n ICD 10: N30.10; Interstitial cystitis; <\/strong>Symptoms primarily localized to the bladder, such as<\/p>\n urinary frequency and urgency. Patients complain of pain with a full bladder that is relieved upon<\/p>\n voiding. Diffuse chronic pain and dyspareunia are common and often indistinguishable from<\/p>\n endometriosis.<\/p>\n ICD 10: Ovarian cyst (benign); <\/strong>May be asymptomatic with an incidental pelvic mass or<\/p>\n present with acute rather than chronic pain, such as in the case of hemorrhagic cysts.<\/p>\n Plan<\/strong><\/p>\n Laboratory Exam:<\/strong><\/p>\n Ultrasound. To identify cysts associated with endometriosis (endometriomas).<\/p>\n Magnetic resonance imaging (MRI). To obtain a detailed information about the location<\/p>\n and size of endometrial implants.<\/p>\n
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