*NURSING > CASE STUDY > MSN 5500 Soap Notes #9 DYSMENORRHEA- 100% Complete (All)

MSN 5500 Soap Notes #9 DYSMENORRHEA- 100% Complete

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Encounter date: 10/09/17 Patient Initials: H.T. Gender: Female, Age: 19 years Weight 124 Height 5.6 Pregnant:0 Gestational Age: None. Abort: 0. Chief Complaint:” my cycles are so unpredictable and i... rregular and painful” HPI: A 19yearold Hispanic female patient who came to the office for patient presents for her first gynecological exam with complaints of irregular periods and painful and reports she only has 78 periods per year on average since beginning her cycles at 11 years old. Denied pain at this time. Menstrual history: Irregular 28day menstrual cycles, duration for 910 days irregular, and no report intermenstrual bleeding Age at menarche: 11 years Last menstrual period: 09/10/17 Menstrual pattern: Irregular Cycle: length: 32 days Duration of flow: 910 days Amount of flow: Heavy menstrual flow Bleeding pattern: report intermenstrual bleeding associated pain (dysmenorrhea) Break through bleeding: None Premenopause/menopause: Yes (dysmenorrhea) Vasomotor symptoms: no Hormone replacement therapy: no Contraception: No Current method: No Cervical and vaginal cytology: Yes, last year. Most recent Pap smear result: NO History of sexually transmitted infections: None Vaginitis: None History of pelvic inflammatory disease: None Any difficulty conceiving in past: None Sexually active: No History of sexual abuse or sexual assault: None Obstetric history: G0 T0 [Show More]

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