*NURSING > CASE STUDY > MSN 5500 Soap Notes #9 DYSMENORRHEA- 100% Complete (All)
MSN 5500 Soap Notes #9 DYSMENORRHEA/MSN 5500 Soap Notes #9 DYSMENORRHEA/MSN 5500 Soap Notes #9 DYSMENORRHEA Paper Contains Review of Systems, Physical Examination, Assessment and Treatment Patient Ini... tials: 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 irregular and painful” HPI: A 19-year-old 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 7-8 periods per year on average since beginning her cycles at 11 years old. Denied pain at this time. Menstrual history: Irregular 28-day menstrual cycles, duration for 9-10 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: 9-10 days Amount of flow: Heavy menstrual flow Bleeding pattern: report intermenstrual bleeding associated pain (dysmenorrhea) Break through bleeding: None Pre-menopause/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: G-0 T-0 P-0 A-0 L-0 Describe any maternal, fetal, or neonatal complications: None Allergies: None PMH: None Current or past illnesses: None. Hospitalizations: None Past surgical history: None Current Meds: None Family Hx: Mother and Father (alive) and healthy. Immunization: Update and complete. Social history: She go to school. Lives: Home with 2 siblings Smoke and Recreational Drug Use-None [Show More]
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