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Clinical Documentation Template – Abnormal Vaginal Bleeding

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Clinical Documentation Template – Abnormal Vaginal Bleeding

ID:

Client’s Initials*: ___L.R.C___ Age_ 45years old ____ Race_ _Asian__ Gender_Female_ Date of Birth_Jan 1, 1979__ Insurance _____N/A____   Marital Status ____Married_______

L.R.C. came to the clinic unaccompanied and presented in a good state of mind with the capacity to provide reliable and accurate historical health information and medical background.

 Subjective:

CC: “I am here to get checked for my abnormal vaginal bleeding”.

 

HPI:

L.R.C., an Asian 45-year-old woman, presents herself to the clinic with a complaint of abnormal vaginal bleeding and spotting. She states that the symptoms began two weeks after her last menstruation. She notes that she is concerned about the possibility of her cervical polyps recurring. The cervical polyps were diagnosed and removed on June 15, 2023. The spotting is localized in the vaginal and has been persistent and shows no signs of stopping. She also notes that she experiences spotting every time she urinates and wipes, as well as on her panty liner. She reports that the spotting worsens with sexual activity and results in increased bleeding. She describes the spotting as bothersome as she finds no relief with using a panty liner. However, she reports that the spotting is not associated with any pain. She notes that she has tried various ways to address the issue, including increased resting and hydration, under the assumption that stress might be a contributing factor. However, the bleeding has remained persistent. Additionally, she reports feeling constantly fatigued, weak, and occasionally dizzy. She states that the last time she did a Pap smear and human papillomavirus (HPV) test was two years ago. The results of the Pap smear were unremarkable. She reports that the bleeding and spotting occur at any time during the day or night and describes its severity as a 6 out of 10. She also has a history of mild anemia for a couple of months now, which is related to and has been worsened by her vaginal bleeding.

Past Medical History:

  1. Hx of Mild Anemia: L.R.C. has a mild iron-deficiency anemia for the last several months. The mild anemia is related to and made worse by her vaginal bleeding. The mild anemia now appears to be worsening. The last Hb test was at 10.1 g/dL.
  2. Hx of Cervical Polyps. Diagnosed and removed on June 15, 2022

 

  1. PAPS Smear done on June 2, 2022, with normal results.
  2. Mammography done last in April 2019 with a normal result.
  3. HPV exam done on June 2, 2022, with a normal result.
  4. Reports full immunization with all childhood vaccines. No status report on seasonal flu and recent vaccines.

Note: L.R.C. has maintained a regular health check-up as a form of preventive care, which is essential for maintaining optimal health.

  1. Rhinoplasty on September 14, 2024.
  2. A Caesarian Section on July 12, 2010, while having her third-born child.
  1. Hospitalized twice, first during the rhinoplasty and second during the CS. She has no other reported history of hospitalization.
  1. LMP – May 3, 2024.
  2. Pregnancy status – Not pregnant
  3. Para 3, G 0.
  4. Menopause – Not yet. Although L.R.C. has not yet reached menopause, some women have been found to reach pre-menopausal and menopausal stages as early as 45 years, with a heightened risk of abnormal uterine bleeding (Wouk & Helton, 2019).

Allergies:

Medications:

L.R.C. has been on the following supplements for her iron-deficiency anemia:

 Family History:

Mother:

Father:

Sister:

Brother:

She has children:

Social History:

Sexual history and contraception/protection

-Chemical history (tobacco/alcohol/drugs)

Other:

 

ROS

Constitutional: Reports no unprecedented weight loss or gain. She reports feeling constantly fatigued, weak, and occasionally dizzy.

Cardiovascular: No chest pain, fast heartbeats, or abnormal heartbeats

Gastrointestinal: No nausea and vomiting, or abdominal pain, no reported changes in bowel habit

Genitourinary: Abnormal vaginal bleeding with a severity of 6/10, no associated pain or cramping, last menstrual period reported at an estimated two weeks ago, normal LMP, no reported changes in urinary and bladder habits, has a history of cervical polyps diagnosed and removed two years ago (2022). History of cervical polyps, last Pap smear, and HPV test two years ago, sexually active with one partner, uses condoms, no history of STIs, no postcoital bleeding

Integumentary & breast: Has three successful pregnancies, currently on Mirena IUCD, no history of STIs

Sexual activity and any related symptoms like postcoital bleeding

Neurological: Occasionally feels dizzy

Psychiatric: Majorly anxious or stressed, of sound mind

Endocrine: No heat or cold intolerance, no symptoms of thyroid dysfunction, or changes in appetite or weight

Hematologic/Lymphatic: Easy bleeding, especially with sexual activity, history of mild anemia

Allergic/Immunologic: No known drug, food, or environmental allergies, no reported recurrent infections

Objective

 Vital Signs:

 

Height: 5’6”

Weight: 132 lbs

BMI: 21.31

Labs, radiology, or other pertinent studies:

Physical Exam

 Assessment

Differentials:

  1. Cervical Polyps: This is the main differential. It is based on the fact that a majority of females with abnormal bleeding around the genital area usually often present with a complaint of vaginal bleeding (Kaunitz, 2024). In most of these cases, such bleeding is usually related to an intra-uterine cause, but it may also develop as a result of issues within the lower genital tract, such as the cervix, vagina, and vulva (Kaunitz, 2024). Noting that the patient has a history of cervical polyps, the abnormal vaginal bleeding may be associated with such polyps. Evidence also links such bleeding to the development of cervical polyps (Marnach & Laughlin-Tommaso, 2019). Secondly, the patient presents with symptoms that are associated with cervical polyps, including abnormal vaginal bleeding, intermenstrual bleeding, bleeding after sexual activity, and blood spotting.
  2. Endometrial hyperplasia. Endometrial hyperplasia is a possible diagnosis related to the abnormal uterine bleeding the patient presents with, as it is linked to abnormal uterine and vaginal bleeding (Henderson et al., 2024; Reed & Urban, 2024). It is also common in women in perimenopause and postmenopausal ages. Noting the patient is aged 45 years old, the possibility of endometrial hyperplasia being the cause of the abnormal vaginal bleeding is high (Patel, 2019). Another rationale for this diagnosis is that the patient has observed persistent spotting and bleeding between her periods.
  3. Endometrial carcinoma. Endometrial carcinoma may be a possible cause of abnormal vaginal bleeding, noting that there is a possibility of polyps and endometrial hyperplasia progressing to endometrial cancer (Nees et al., 2022). However, the condition, despite its possible presentation, may be ruled out based on the patient’s age and her having a history of cervical polyps.

 Diagnosis

Cervical polyps   N84.1.

Plan

Cervical Polyps

Diagnostics

Treatment

Education:

Follow Up:

Endometrial Hyperplasia

Diagnostics:

Treatment:

Education

Follow Up

Endometrial carcinoma

Diagnostics

Treatment

Education

Follow Up

References

Cea García, J., Márquez Maraver, F., & Rubio Rodríguez, M. C. (2022). Cross-sectional study on the impact of age, menopause and quality of life on female sexual function. Journal of Obstetrics and Gynaecology, 42(5), 1225–1232. https://doi.org/10.1080/01443615.2021.1945017

Henderson, I., Black, N., Khattak, H., Gupta, J. K., & Rimmer, M. P. (2024). Diagnosis and management of endometrial hyperplasia: A UK national audit of adherence to national guidance 2012-2020. PLoS Medicine, 21(2). https://doi.org/10.1371/JOURNAL.PMED.1004346

Kaunitz, A. M. (2024). Causes of female genital tract bleeding. https://sso.uptodate.com/contents/causes-of-female-genital-tract-bleeding?search=Cervical+Polyps&source=search_result&selectedTitle=2%7E29&usage_type=default&display_rank=2

Marnach, M. L., & Laughlin-Tommaso, S. K. (2019). Evaluation and management of abnormal uterine bleeding. Mayo Clinic Proceedings, 94(2), 326–335. https://doi.org/10.1016/J.MAYOCP.2018.12.012

Meybodi, N. F., Karimi-Zarchi, M., Allahqoli, L., Sekhavat, L., Gitas, G., Rahmani, A., Fallahi, A., Hassanlouei, B., & Alkatout, I. (2020). Accuracy of the triple test versus colposcopy for the diagnosis of premalignant and malignant cervical lesions. Asian Pacific Journal of Cancer Prevention : APJCP, 21(12), 3501. https://doi.org/10.31557/APJCP.2020.21.12.3501

Nees, L. K., Heublein, S., Steinmacher, S., Juhasz-Böss, I., Brucker, S., Tempfer, C. B., & Wallwiener, M. (2022). Endometrial hyperplasia as a risk factor of endometrial cancer. Archives of Gynecology and Obstetrics, 306(2), 407–421. https://doi.org/10.1007/S00404-021-06380-5/TABLES/2

Patel, B. M. (2019). Endometrial hyperplasia: Diagnosis and management. Preventive Oncology for the Gynecologist, 25–43. https://doi.org/10.1007/978-981-13-3438-2_3

Pegu, B., Srinivas, B. H., Saranya, T. S., Murugesan, R., Thippeswamy, S. P., & Gaur, B. P. S. (2020). Cervical polyp: evaluating the need of routine surgical intervention and its correlation with cervical smear cytology and endometrial pathology: A retrospective study. Obstetrics & Gynecology Science, 63(6), 735. https://doi.org/10.5468/OGS.20177

Reed, S. D., & Urban, R. R. (2024). Endometrial hyperplasia: Clinical features, diagnosis, and differential diagnosis. https://sso.uptodate.com/contents/endometrial-hyperplasia-clinical-features-diagnosis-and-differential-diagnosis?search=endometrial+hyperplasia&source=search_result&selectedTitle=1%7E100&usage_type=default&display_rank=1

Uglietti, A., Buggio, L., Farella, M., Chiaffarino, F., Dridi, D., Vercellini, P., & Parazzini, F. (2019). The risk of malignancy in uterine polyps: A systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology, 237, 48–56. https://doi.org/10.1016/J.EJOGRB.2019.04.009

Williams, P. M., & Gaddey, H. L. (2020). Endometrial biopsy: Tips and pitfalls. American Family Physician, 101(9), 551–556. https://www.aafp.org/pubs/afp/issues/2020/0501/p551.html

Wouk, N., & Helton, M. (2019). Abnormal uterine bleeding in premenopausal women. American Family Physician, 99(7), 435–443. https://www.aafp.org/pubs/afp/issues/2019/0401/p435.html

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Question 

1.) Create a pretend SOAP NOTE ABNORMAL VAGINAL BLEEDING DUE TO CERVICA POLYPS. I ATTACHED some details. Please DO NOT use a textbook as a reference. We need to use the Clinical Guidelines. You can also use my up-to-date account to find clinical guidelines and treatments

Abnormal Vaginal Bleeding

Abnormal Vaginal Bleeding

2. I attached a sample of SOAP NOTE
3.) This is a FOCUS SOAP NOTE on Abnormal Vaginal Bleeding so please only include what is pertinent on ROS and Physical exam base on the complaint. You can use our SOAP NOTE TEMPLATE
4.) On the Assessment part put rationale why it is your main diagnosis and also rationales for the two differentials on why it is not the main diagnosis.
5.) Please make sure to put intext citations on assessment, treatment, diagnostics etc. that needs references.
6.) Please use a Clinical Guidelines reference within the last 5 years,
7.) Make sure the correct spelling, grammar, and abbreviation rules are correct too.
8.) PLEASE MAKE SURE IT’S PLAGIARISM FREE.

PRETEND DETAILS:

ID:
The patient, identified by the initials L.R.C., is a 45-year-old Asian female born on January 1, 1979. She is married and arrived at the facility unaccompanied, driving herself. Despite being alone, the patient presented in a good state of mind, demonstrating the ability to provide reliable and accurate historical information about her health and medical background.

Subjective:
CC: “I am here to get checked for my abnormal vaginal bleeding”.

HPI:
L.R.C is a 45-year-old Asian female who presents herself to the clinic with complaints of abnormal vaginal bleeding and spotting. She states that the symptoms began two weeks after her last menstruation and expresses concern about the possibility of her cervical polyps recurring. The spotting, localized in the vaginal area, has been persistent and shows no signs of stopping. L.R.C describes experiencing spotting every time she urinates and wipes, as well as on her panty liner. She reports that the spotting worsens during sexual activity, leading to increased bleeding. Despite using panty liners, she finds no relief from the spotting, which she describes as bothersome but without associated pain. In an attempt to address the issue, she tried resting and increasing hydration under the assumption that stress might be a contributing factor, but the bleeding persisted. Additionally, she reports feeling constantly fatigued, weak, and occasionally dizzy. She states that the last time she did a Pap smear and human papillomavirus (HPV) test was two years ago. The results were unremarkable. The bleeding, according to he,r can occur at any time during the day or at night. She ascribes to the bleeding a severity of 6/10.

Past Medical History:
● Medical problem list:
a. Mild Anemia: She has been having mild iron-deficiency anemia for the last several months. This has been caused by her vaginal bleeding and now appears to be worsening. The last hemoglobin (Hb) test done a month ago showed a value of 10.1 g/dL.
b. Cervical Polyps were diagnosed and removed last June 15, 2022
● Preventive care:
a. PAPS Smear – June 2, 2022 – normal result.
b. Mammography – normal result. It was done last in April 2019.
c. HPV – June 2, 2022 – normal result.
● Surgeries:
a. Rhinoplasty – September 14, 2024.
b. Caesarian Section – July 12, 2010, while having her third-born child.
● Hospitalizations: She has no history of current or recent hospitalizations, apart from those of the two surgeries above.
● Others:
a. LMP – May 3, 2024.
b. Pregnancy status – Not pregnant
c. Para 3, G 0.
d. Menopause – Not yet.
Allergies:
• No known drug allergies (NKDA).
• No food allergies known.
• No environmental allergens known.

Medications:
She has been on the following supplements for her iron-deficiency anemia (Rosenthal & Burchum, 2020):
i. Ferrous sulphate 325 mg (65 mg of elemental Fe) orally TDS.
ii. Vitamin C 500 IU orally O.D.
iii. Folic acid 400 mcg orally O.D.

Family History:
The patient states during the interview that her mother died at the age of 31 years due to complications associated with pregnancy. She says the mother had developed recalcitrant hypertension when she was pregnant with their last born (they are three). She died on the operating table when the child was being extracted. The child survived. Her father is still alive and is 71 years old. He has a significant history of hypertension and is on treatment for it. She also has a sister who is 43 years old and has a history of hypertension too. This sister also has high cholesterol (hypercholesterolemia) and type 2 diabetes mellitus. There is a brother who is 37 years old. He is healthy with no chronic medical conditions. Her children, aged 21 years (son), 18 years (son), and 12 years (daughter) are all healthy with no medical issues.

Social and Sexual/ Reproductive History:
The client states that she is married to her husband of twenty years and they are still sexually active. She has been using contraception/ protection in the form of Mirena IUCD for the past five years without any associated problems. She avers that her sexual activity is only with one sexual partner and that she is in a monogamous relationship. She denies involvement in any type of extramarital sexual activities and also denies using condoms or any other forms of protection during sex. She denies any history of sexually transmitted infections or STIs since she started being sexually active. Presently, she denies any plans for future pregnancy.

Substance Current Use and History:
This patient denies any chemical use history, such as tobacco smoking, alcohol drinking, or taking drugs and other illegal substances. She also denies ever using any recreational drugs in her life. She also stated that no one in her family has a history of drug or substance use.

Other:
The patient, a Licensed Vocational Nurse currently studying to become a Registered Nurse, lives with her husband and two children in a downtown rental apartment, follows a typical Asian-Filipino diet, and reports limited exercise due to her busy schedule. She has a strong social support system within her closely-knit Asian community, is psychologically and emotionally stable, and has no neurodevelopmental disorders, allowing her to perform all activities of daily living independently.

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