SOAP Note
Name: MR
Date: 04/26/2019 Age: 55 Sex: Female
SUBJECTIVE
CC:
“I’m very concerned about my vaginal bleeding and the abdominal pain is not resolving”
HPI:
A 55-year-old Hispanic patient presents to the clinic complaining about profuse post-coital vaginal bleeding. She has not had irregular bleeding previously and she stays that her monthly menses are usually regular. The patient reports that for several months, she has been experiencing vague lower abdominal pain. Upon further questioning, she also states that she occasionally has foul smelling, blood stained vaginal discharge. MR is unsure of her partner’s sexual activity and they do not use condoms when having sex. She additionally attests that since ten years ago, she has not received gynecological care.
Medications:
Enalapril 20 mg PO daily – For managing hypertension
Atorvastatin 20 mg PO at night– Hyperlipidemia
PMH
Allergies: NKDA
Medication Intolerances: No recorded
Chronic Illnesses/Major traumas: Hyperlipidemia × 4 years, HTN × 5 years
Hospitalizations/Surgeries: N/A
Family History
Parents alive. Mother was diagnosed at age 60 with breast cancer and Father has COPD, HTA and Hyperlipidemia.
Social History
Patient currently works as a cashier in a local fashion retail store. She is a 25-pack year cigarette smoker and admits to drinking alcohol occasionally. She denies using marijuana, cocaine, or other illicit substances
ROS
General
Denies fever, weight loss, fatigue, or weakness. Cardiovascular
Does not have chest pain, palpitations, edema and, dyspnea.
Skin
Denies rashes, bruising, delayed healing, bleeding, or any mole/lesion changes Respiratory
Denies any SOB, cough or sputum.
Eyes
Does not wear reading glasses, she denies diplopia or eye pain Gastrointestinal
Patient affirm lower abdominal pain and intermittent cramping. She states that these symptoms have been present for several months now. Denies heartburn or abdominal discomfort. Denies nausea, vomiting or diarrhea.
Ears
Patient reports that her hearing is intact with no notable changes in the recent past Genitourinary/Gynecological
Patient refers plenty post-coital vaginal bleeding. On several occasions, she has noticed a foul smelling, blood stained vaginal discharge. Patient is G3, P3. Pt is not sure about her last Pap. She does not receive regular gynecologic care or attend routine checkups since 10 years ago.
Nose/Mouth/Throat
Denies nasal congestion and other sinus problems. No oral lesions or dental problems. She also denies throat pain Musculoskeletal
Denies muscle pain, joint pain, or stiffness
Breast
Deny tender or mass. Neurological
Deny nervousness, anxiety or irritability.
Heme/Lymph/Endo
WNL Psychiatric
Denies history of mental conditions. She also denies suicide ideation
OBJECTIVE
Weight: 139 lbs BMI: 24.7 Temp:98.6 F BP: 126/65 mmHg
Height: 5’4’’ Pulse: 76 beats/min Resp: 17 breaths/min
General Appearance
Healthy-appearing ,well-nourished Caucasian female who is alert and in no apparent distress
Skin
Skin is warm and dry
HEENT
PERRLA; Extra ocular motions full. Conjunctiva clear. Gross visual fields full to confrontation. TM landmarks well visualized. Neck supple with no masses. No nasal discharge or obstruction.
Cardiovascular
Normal S1 and S2; PMI at the 6th ICS; RRR with no MRG; No thrills or heaves
Respiratory
CTA bilaterally
Gastrointestinal
The abdomen is soft with no enlargement Minimal tenderness across lower abdomen, tenderness greater on left than right side, without guarding or rebound.
Breast
Medium sized breasts, nipples symmetrical without discharge. No masses, lesions, or retraction appreciated on exam. (-) lymphadenopathy bilaterally in axillary region
Genitourinary
External genitalia unremarkable. Speculum examination – reveals large traces of blood noticed in the vaginal vault. Cervix replaced by a 7 cm , friable cervical mass deviated to the right Bimanual examination – reveals 6 cm fixed mass that obliterates left vaginal fornix, no extension to the vagina.
Musculoskeletal
Full ROM. No deformities, cyanosis, edema, or varicosities
Neurological
AAO × 3, pleasant affect. No motor/sensory/perceptual deficits
Psychiatric
A & O × 3. Rate of thoughts logical and normal. Judgment intact. Patient appears content/happy, cooperative, calm, and pleasant.
Lab Tests
Speculum examination – reveals large traces of blood noticed in the vaginal vault. Cervix replaced by a 6 cm , friable cervical mass deviated to the right.
Bimanual examination – reveals 7 cm fixed mass deviating to the left, which obliterates the vaginal fornix, no extension to the vagina.
Thin prep Pap smear – Results abnormal
Urinalysis – Pending results
HPV Test – Positive for HPV 16 and 18
Colposcopy – Abnormal
Special Tests
Cervical Biopsy – Pending
Diagnosis
Include at least three differential diagnosis
D25.9 Leiomyoma of uterus, unspecified
O86.11 Cervicitis
C54.1 Malignant neoplasm of endometrium.
N84.1 Polyp of cervix uteri
Final diagnosis
C53.9 Malignant neoplasm of cervix uteri, unspecified (Both subjective and objective findings support this definitive diagnosis. Symptoms such as heavy post-coital vaginal bleeding, blood stained vaginal discharge, abdominal pain, as well as positive findings of fungating, friable cervical mass, positive HPV 16 and 18, and abnormal Pap and colposcopy all suggestive of cervix cancer).
PLAN including education
Plan:
Further testing
The practitioner ordered an MRI scanning for radiological scanning. According to clinical guidelines by the Scottish Intercollegiate Guidelines Network (2008), consistent evidence exists suggesting that MRI is more accurate as compared to CT for radiological staging of cervical carcinoma, with staging accuracies ranging from 78-97%. The clinical guidelines also affirm that “thin section axial and sagittal T2 sequences including axial oblique sections perpendicular to the long axis of the cervix, are of most value in primary tumor assessment” (p. 8). Apart from primary tumor assessment, MRI is also superior to other imaging studies in in assessments of vaginal invasion, bladder and rectal invasion, metastatic lymphadenopathy, and parametrial staging. Findings from this testing revealed that the patient had Stage IIA2 cervical cancer.
Medication
The recommended treatment approach for this patient with Stage IIA2 cervical cancer was initiating chemotherapy using cisplatin 50 mg/m2 on day 1 plus paclitaxel 135 mg/m2 every 3 weeks. Guidelines from the Scottish Intercollegiate Guidelines Network (2008) indicate that despite low response rates, cisplatin remains the standard chemotherapy because of its effects on overall survival and time to progression. The combination therapy of cisplatin plus paclitaxel also improves the overall quality of life in patients with cervical cancer (CDC, 2017). In order to guarantee the success of this therapy, practitioners must ensure that they prescribe, administer, dispense, and supervise in an effective and safe manner in accordance with established clinical guidelines such as those advocated by the Joint Collegiate Council for Oncology.
Education
The patient was educated about the signs and symptoms that she should monitor for complications associated with cervical cancer. Palmer & Gillespie (2010) contend that such warning signs include active bleeding, increased pus-like discharge, serious cramping, fever, and intense abdominal pain. Patient notified to return immediately to the ED if she notices a flare-up of these warning signs. DT also notified about some self-care practices that could help her in managing her cervical cancer. The clinician additionally informed the patient about potential cervical cancer risk factors that she should strive to modify. Recognized risk factors for developing this malignancy include cigarette smoking, HPV infection, and socioeconomic status (Schwinghammer & Koehler, 2014). Furthermore, the clinician provided sex education to the patient, as women with cervical cancer often suffer from sexual problems including loss of libido and decreased orgasm.
Nonmedication treatments
An effective Nonmedication treatment for cancer of the cervix is radical hysterectomy (RH). This surgical procedure involves the en-bloc removal of the cervix, uterus, upper vagina, and parametrial tissues (Scottish Intercollegiate Guidelines Network, 2008). Nevertheless, in order to minimize post-surgical morbidity when after performing RH, it is paramount for practitioners to correctly and accurately assess the size of primary tumor radiologically and ensure that there is no pelvic lymphadenopathy. Hormone replacement therapy (HRT) is also an effective no pharmacological intervention for patients with cervical cancer, particularly those with absent ovarian function following radiotherapy and/or chemotherapy. Schwinghammer & Koehler (2014) reiterate that HRT significantly reduces post-menopausal symptoms as well as long-term post-radiation vaginal, bladder, and rectal complications.
Follow-up
Patient notified about regular follow-ups at 6 months’ intervals, or should the symptoms worsen or fail after beginning the chemotherapy treatment.
References
CDC. (2017, February). How Is cervical cancer diagnosed and treated? Retrieved from https://www.cdc.gov/cancer/cervical/basic_info/diagnosis_treatment.htm
Palmer, J., & Gillespie, A. (2010). Diagnosis and management of primary cervical carcinoma. Trends in Urology Gynaecology & Sexual Health, 15(3), 24-30. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/tre.151/pdf
Schwinghammer, T., & Koehler, J. (2014). Pharmacotherapy casebook: A patient-focused approach (9 ed.). McGraw Hill Professional.
Scottish Intercollegiate Guidelines Network. (2008). Management of cervical cancer: A national clinical guideline. Retrieved from http://www.sign.ac.uk/assets/sign99.pdf
