Cervical motion tenderness icd 10

Soap Note 1: Trichomoniasis vulvovaginitis. 1

Subjective:

CC: “I’m having vaginal discharge and lower abdominal pain”.

History of Present Illness: A 46-year-old, female of Hispanic origin who comes to our

office and refers her has lower abdominal pain and vaginal discharge of five days duration,

yellowish color and strong smell, Denies history of STDs, fever, vomiting, nausea. Reports

Douches regularly after menses and intercourse. Denies nauseas, vomiting, menstrual troubles,

headaches, or pain of other type.

Race: Hispanic

Past Medical History: None

Past Surgical History: None

OB History: G2P0T2A0L2. (Delivers into hospital without complications).

Menarche at age 11, LMP 10 days ago.

Immunizations: Current and complete.

FMH: Father High Cholesterol; Mother HTN

SOCHX: Does not smoke, nor alcohol or drugs. Lives with family

Allergies: No known drug or food allergies

Medications: None

Marital Status: Married 14 years ago.

Review of Systems:

General: Denies malaise, chills, night sweats, weight gain, or weight loss.

Integumentary: Denies rashes, pigmentation changes, lesions, or hair or nail changes.

Eyes, ears, eyes, nose, and throat: Denies headache or dizziness. Denies blurred, double

vision, or use of glasses. Denies earaches or hearing loss. Denies nasal congestion or stuffiness,

SOAP NOTE 1: TRICHOMONIASIS VULVOVAGINITIS. 2

runny nose or nosebleed. No sinus pain or pressure. Visits dentist every 6 months. No trouble

swallowing or slurred speech.

Cardiovascular: Denies chest pain, palpitations, dyspnea, or orthopnea.

Respiratory: Denies shortness of breath, dyspnea on exertion, cough, or wheezing.

Gastrointestinal: Reports nausea and lower abdominal pain. Denies vomiting or blood in

stool.

Urinary: Denies urgency, dysuria, or urinary incontinence.

GYN: refers has vaginal secretion yellow color, fish odor, no urinary symptoms reported.

Musculoskeletal: Denies any history of falls and any loss of range of motion.

Neurologic: Denies weakness, dizziness, lightheadedness, tremors, seizures, gait

problems, speech difficulties, or memory problems.

Endocrine: Denies heat or cold intolerance, polyuria, polydipsia, or history of diabetes.

Psychiatric: Report slight anxiety due to malodorous vaginal discharge. Denies

depression or any thoughts to harm self or others. Denies any hospitalization or

institutionalization due to a psychiatric disorder. Denies any psychosocial/emotional disorder

now.

OBJETIVE DATA

General: is awake, alert, and oriented to time, space, and person. Speaks clearly and

follows simple commands. Well developed, well-nourished and in no acute distress.

Vital Signs:

BP 110/82 mmhg

Pulse 82 x min,

Respirations 16 x min,

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Temperature 98.6 degrees Fahrenheit

Pain scale 3/10,

Height 5'6''

Weight 168 ps.

SO: 100 %.

Integumentary: Normal general appearance. Warm, moist, good skin turgor. No cyanosis,

rashes, or lesions noted.

HEENT: Normocephalic, atraumatic. Ears: right and left non-tender to touch, no

drainage, tympanic membrane pearly white, cone of light visible, normal hearing to soft voice.

Eyes: PERRLA 3 mm bilaterally, no drainage, no discoloration of sclera, EOM's intact. Nose: no

drainage noted, inferior and middle turbinate's, pearly white moist, patent, frontal and maxillary

sinuses non-tender. Mouth: All teeth present and free of visible caries, tongue freely movable and

non-tender temporomandibular joint. Throat: Trachea midline, no exudates noted, uvula midline

movable, gag reflex intact. Lymph nodes: freely movable non-tender, not enlarged. Mastoid

process non-tender, no swelling or redness bilaterally.

Neck: Soft, supple. No rigidity, lymphadenopathy, bruits, or thyroid enlargement.

Cardiovascular: Heart rhythm is regular with a controlled ventricular rate. S1, S2

auscultated. No heaves, thrills, rubs, or gallops present. No carotid bruits noted upon

auscultation. No jugular venous distention. Peripheral pedal pulses +2 present bilaterally.

Lungs: Bilateral clear lung sounds with symmetrical chest wall expansion.

Abdomen: Soft with right and left lower quadrant deep palpation tenderness with active

bowel sounds in all four quadrants. No bruits heard in abdominal aorta, renal arteries, or iliac

SOAP NOTE 1: TRICHOMONIASIS VULVOVAGINITIS. 4

arteries. Tympanic percussion noted throughout. Liver and spleen non-palpable. No

guarding or rebound tenderness.

Pelvic: No inguinal lymphadenopathy. External genitalia are normal appearing with no

lesions. Bartholin's glands are Nontender and normal in size, and vaginal yellow discharge is

noted. Urethral orifice is normal. Speculum exam reveals a moderate amount of whitish

discharge, Cervix red, no lesions, cultures were taken for gonorrhea and chlamydia testing. On

bimanual examination, there is no cervical motion tenderness and the cervix is firm and normal

fornixes. The uterus is palpable in retroverted position, mobile, smooth, Nontender, and normal

size. Ovaries are not palpable and there is no adnexal tenderness or masses. Pain 3/10 scale.

Extremities: No edema, clubbing, or cyanosis. Capillary refill less than three seconds.

Equal hair distribution on all extremities.

Musculoskeletal: Full range of motion in all extremities. No abnormalities in gait or

movement.

Neurologic: Cranial nerve 2-12 grossly intact. Finger-nose testing performed and

adequate

ASSESSMENT:

ICD 10: A59.01; Trichomoniasis vulvovaginitis; is a sexually transmitted infection (STI)

caused by the motile parasitic protozoan Trichomonas vaginalis. It is one of the most common

STIs, both in the United States and worldwide. Women with trichomoniasis frequently report an

abnormal vaginal discharge, which may be purulent, frothy, or bloody. Although frothy vaginal

discharge is thought to be the classic presentation of trichomoniasis, women with trichomoniasis

also commonly report the following: Abnormal vaginal odor (often described as musty),

Vulvovaginal itching, burning, or soreness; Dyspareunia (pain during sexual intercourse), often

SOAP NOTE 1: TRICHOMONIASIS VULVOVAGINITIS. 5

the major complaint, Dysuria (pain during urination), Postcoital bleeding, Lower abdominal

pain, in addition to its associated signs and symptoms, trichomoniasis may lead to cervicitis. This

is characterized by 2 major signs, as follows: Purulent discharge in the endocervical canal, easily

induced endocervical bleeding; T vaginalis infection is also one of the top 3 causes of vaginitis.

Differential Diagnosis:

1) (ICD-10)- N72; Cervicitis is an inflammation of the uterine cervix, characteristically

diagnosed by: a visible, purulent or mucopurulent endocervical exudate in the endocervical canal

or on an endocervical swab specimen and/or (2) sustained, easily induced endocervical bleeding

when a cotton swab is gently passed through the cervical os. A normal cervix is pictured below.

2) ICD 10: A54.9; Gonorrhea is a purulent infection of the mucous membrane surfaces

caused by Neisseria gonorrhoeae. N gonorrhoeae is spread by sexual contact or through

transmission during childbirth.

3) ICD 10: N34.1; Urethritis is defined as infection-induced inflammation of the urethra.

The term is typically reserved to describe urethral inflammation caused by a sexually transmitted

disease (STD), and the condition is normally categorized as either gonococcal urethritis (GU) or

nongonococcal urethritis (NGU).

PLAN:

TESTS - Vaginal saline wet mount with pH.

Nucleic acid amplification test (NAAT)

Urine analysis and culture

CBC with sedimentation rate and C-reactive protein

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Pregnancy test Laboratory Results of office diagnostics: - Urine pregnancy test: negative

- Urine dip stick for nitrates: negative - Vaginal saline wet mount: vaginal pH was 6.5.

Microscopy showed WBCs >10 per HPF, trichomonas Positive.

Treatment

Medications attached to this encounter

- Metronidazole 500mg orally twice a day for 14 days, don’t drink alcohol for 24 hours

after taking metronidazole, because it can cause severe nausea and vomiting.

Education:

Increase intake of oral liquid fluids Avoid sexual intercourse during the entire treatment.

Use safe practice sex (condom).

Both you and your partner need treatment at the same time. And you need to avoid sexual

intercourse until the infection is cured, which takes about a week.

Your doctor will likely want to retest you for trichomoniasis from two weeks to three

months after treatment to be sure you haven't been reinfected.

Follow-ups/Referrals:

Follow up in 2 weeks to evaluate patient and laboratory testing results.

Referral none currently.

References:

Vaginitis/Trichomoniasis: Reduce your risk Archived 2018-03-16 at the Wayback

Machine, American Social Health Association. Retrieved March 12, 2018.

Martan, Alois; Citterbart, Karel; et al. (2018). Gynekologie (in Czech) (2nd ed.). Prague:

Galen. p. 136. ISBN 978-80-7262-501-7.

SOAP NOTE 1: TRICHOMONIASIS VULVOVAGINITIS. 7

Munson E (January 2016). "Point: new trichs for "old" dogs: prospects for expansion of

Trichomonas vaginalis screening". Clinical Chemistry. 60 (1): 151–4.