SOAP NOTE for CERVICAL CANCER
CC: “I have been experiencing heavy menstrual bleeding, painful intercourse, and bleeding between periods.”
HPI: The client, R. H is a 28yo Black American female. Upon visiting the clinic at around noon today the client complains of heavy and excessive menstrual bleeding, painful intercourse, and bleeding between periods. The client adds that her menstrual bleeding is accompanied by unbearable pain. R.H have also noticed blood stains between monthly periods severally. She further reports experiencing unbearable pains during sexual intercourse. The pain makes it challenging to have sexual intercourse with her boyfriend. She also reports persistent lower back pain and vaginal bleeding following sexual intercourse. The client reveals that the symptoms have persisted for the last six months, making her concerned about her health. The client denies foul-smelling vaginal discharge, itchiness, redness, or swelling around the vulva or vagina.
Medications: Denies any current medication.
PMH
Allergies: Denies food, drug, or environmental allergies.
Medication Intolerances: The client denies a history of medication intolerances.
Immunizations: Reports that her childhood immunizations are up to date. Received flu vaccine July 2021.
Chronic Illnesses: Denies history of long-term illness.
Hospitalizations: Denies hospitalization history.
Surgeries: The client denies past surgeries.
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Family History: Father: The client reports that her father is 63yo with hypertension and high cholesterol level. Her mother died of human papillomavirus infection (HPV) at 57yo, 5 years ago. She has three siblings, two sisters and one brother. The elder sister was diagnosed with ovarian cysts 2 years ago. Her brother has alcohol use disorder. Her younger sister is healthy with no known health condition.
Social History: The client is a banker and lives within the city with her father and her two siblings. However, she spends time at her boyfriend’s house over the weekends and during holidays. She will be relocating to her three-bedroomed mansion by December 2022. She enjoys reading novels, watching documentaries, traveling, swimming, and hiking. She also likes spending time with her family, boyfriend, and friends. She denies taking alcohol or using illegal substances, including marijuana, heroin, or cocaine. She reports smoking cigarettes.
Sexual/ Reproduction History: The client is heterosexual and sexually active with a single intimate partner. She reports engaging in sexual intercourse with her boyfriend regularly. She denies using any contraceptives. The client denies having a child or being pregnant. Her last monthly period was 2nd August 2022. The client denies being pregnant.
Health Maintenance/Promotion: She takes a balanced diet and engages in physical activities. She takes a minimum of 8 glasses of water daily. Perform self-breast examination regularly.
ROS
General: The client denies fatigue, weakness, or weight loss.
HEENT: Denies head injuries. Denies eye pain, blurred vision, or eye discharge. Denies ear pain or hearing difficulties. Denies nasal blockage or runny nose. Denies tonsils.
Neck: Denies pain or neck stiffness.
Breast: The client denies breasts bump or masses following self-breast examination
Respiratory: The client denies wheezing, coughing, or sputum production.
Cardiovascular: She denies palpitation, edema, or chest pains.
Gastrointestinal: She denies abdominal pains. She denies constipation, nausea, or vomiting.
Genitourinary: The client reports heavy and excessive menstrual bleeding, painful intercourse, and bleeding between periods. She reports vaginal bleeding following sexual intercourse. The client reveals that the symptoms have persisted for the last six months. The client denies foul-smelling vaginal discharge, itchiness, redness, or swelling around the vulva or vagina.
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Musculoskeletal: The client reports experiencing severe and persistent lower back pains. She reports muscle rigidity, stiffness, and swelling.
Neurological: She denies numbness, migraines, fainting, dizziness, or seizures.
Psychiatric: She denies anxiety, sleeping difficulties, depression, or suicidal thoughts.
Skin: She denies cracking, rashes, or pigmentation.
OBJECTIVE DATA
Physical Exam
Vitals: BP: 129 / 84; HR: 78; RR 18: Pulse Ox: 98%; Blood Glucose 99; T 97.0 F; Weight 84kg; Height: 170 cm; and BMI: 29.0.
General: The client is well-groomed and well-nourished. She looks younger than her ideal age. She comes to the clinic accompanied by her boyfriend. She is neat, well-groomed, and presentable. She is appropriately dressed for today’s weather, her age, and time of the year. She seems to be in mild distress. She is alert and oriented to place, persons, situation, and time. Her judgment and affect are good. She depicts a strong thought process. She speaks in a clear voice and normal tone. She is future-oriented.
HEENT: No deformities to the scalp or scars on the head. Equally round pupil at 2mm and reactive to light. Clear conjunctiva and white scleral. Ears have normal external structures. No drainage on bilateral external auditory. Tympanic membranes with no bulging or redness. Clear nasal turbinates. No bleeding or lesions. Pink and moist mucus membranes. No ulcers on the gums. The uvula is located on the midline. The trachea is on the midline.
Neck: Non-tender and supple neck. No shoulder drooping was noted.
CV: Regular heart rate and rhythm with the presence of S1 and S2. No carotid bruits, gallops, or murmurs.
Lungs: Symmetrical chest movement. No wheezing.
ABD: Bowel sounds normal in all quads. Non-tender, soft, and non-distended abdomen. The lower abdomen is tender and bilaterally.
GU: Blood spots were noted in the urine sample. No vaginal discharge. The client declines the rectal exam.
MSK: Normal muscle tone and motor strength.
Neuro: Symmetrical movement noted in all extremities.
Psych: Seems anxious and agitated. Appears in mild distress.
Skin: No pigmentation or skin looseness.
Diagnostics
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A Pap test: Results indicated abnormal cells, including the presence of cancer cells in the cervix. HPV DNA test: The test was performed to test cells collected from the cervix for infection. Results indicated the presence of HPV infection.
Pregnancy test: Negative
ASSESSMENT
Differential Diagnosis
- Cervical Cancer – Pertinent diagnosis
- Cervical polyp,
- Cervical leiomyoma,
- Cervical ectopic pregnancy.
Cervical Cancer
Cervical cancer is the primary diagnosis for this client. It is characterized by bleeding or spotting between periods, bleeding after sexual intercourse, pain or discomfort during sexual intercourse, vaginal discharge with a strong odor, pelvic pain, or vaginal discharge tinged with blood (Cohen et al., 2019). The client reports heavy and excessive menstrual bleeding, painful intercourse, bleeding between periods, and vaginal bleeding following sexual intercourse. Additionally, her Pap test results indicated abnormal cells, while the HPV DNA test indicated the presence of HPV. Thus, cervical cancer qualifies as the client’s primary diagnosis.
Cervical Polyp
A cervical polyp is a potential diagnosis for this client. It is characterized by unusual vaginal bleeding such as following sexual intercourse, bleeding between menstrual periods, and yellow or white mucous vaginal discharge (Hama Saman, 2018). The client qualifies for this diagnosis since she reports heavy and excessive menstrual bleeding, painful intercourse, bleeding between periods, and vaginal bleeding following sexual intercourse. However, the client denies vaginal discharge; hence this diagnosis is ruled out.
Cervical Leiomyoma
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The client reports heavy and excessive menstrual bleeding, painful intercourse, bleeding between periods, and vaginal bleeding following sexual intercourse. Thus, she qualifies for this diagnosis, which is characterized by heavy bleeding, fatigue and weakness, painful sexual intercourse, and vaginal discharge (Ferrari et al., 2021). Nonetheless, this diagnosis is ruled out following the absence of significant symptoms, including fatigue and weakness, and vaginal discharge.
Cervical Ectopic Pregnancy
The last diagnosis for this client is cervical ectopic pregnancy, which is characterized by uterine bleeding without cramping pain and a soft and enlarged cervix. The client qualifies for this diagnosis since he reported bleeding between monthly periods. However, this condition is ruled out since the client’s last monthly period was 2nd August 2022. Additionally, her pregnancy test was negative.
TREATMENT PLAN
- The client was educated about cancer staging and the likelihood of being cured if the cancer is in its early stages.
- Another gynecologist was involved in client’s further screening and treatment.
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References
Cohen, P. A., Jhingran, A., Oaknin, A., & Denny, L. (2019). Cervical cancer. The Lancet, 393(10167), 169-182. DOI:https://doi.org/10.1016/S0140-6736(18)32470-X
Ferrari, F., Forte, S., Valenti, G., Ardighieri, L., Barra, F., Esposito, V., … & Odicino, F. (2021). Current treatment options for cervical leiomyomas: A systematic review of literature. Medicina, 57(2), 92. Doi: 10.3390/medicina57020092
Hama Saman, O, E. (2018). Cervical polyp. Research Gate. DOI: 10.13140/RG.2.2.35673.67685
Gynecology SOAP note FOR CERVICAL CANCER