Exam (elaborations) NURS 6551 Week 11 SOAP Note Walden University

Exam (elaborations) NURS 6551 Week 11 SOAP Note Walden University History of Present Illness (HPI): 33-year-old African American female is seen in office with a complaint of abnormal vaginal bleeding for two weeks. The patient states that initially the bleeding was mild but now alternates between moderate to heavy bleeding. The patient denies any factors that alleviates or worsens the bleeding. She also denies any associated factors or manifestations. Medications: Protonix 40mg daily, diphenhydramine 25mg, 1-2 tabs at bedtime as needed for insomnia. Allergies: denies any known medication or food allergies. Past Medical History (PMH): GERD and insomnia. Denies recent hospitalizations. Past Surgical History (PSH): Appendectomy in 2003. OB/GYN History: Nulligravida. Patient states that her menstrual cycle is irregular and that bleeding during menses lasts 5-6 days with moderate bleeding. The patient also reports that she has been bleeding for two weeks and that the bleeding has increased from mild to moderate/heavy flow. She states that she has a period once every two to three months. Denies a history of sexually transmitted infections and reports that she had one sexual partner with her husband of 10 years. Patient states that she does not use contraceptives since she has never conceived in the past. Personal/Social History: Patient denies smoking or the use of alcohol or illicit drugs. The patient also states that she does not exercise but that her diet consists of baked meats, fruits and vegetables, and she usually drink water or sports drinks. This study source was downloaded by from CourseH on :09:31 GMT -05:00 This study resource was shared via CourseH WEEK 11 SOAP NOTE 3 Immunizations: All immunizations are up to date, including the influenza vaccination. Family History: Patient reports that parents are healthy and living. The patient has two brothers with no medical history. Review of Systems: General: Patient describes general health as good, denies any changes in weight, changes in appetite, nausea, vomiting, fatigue, fevers, or chills. HEENT: Denies any changes in vision, blurry vision, dizziness, light headedness, headaches, or difficulty swallowing. Breasts: Denies breast pain, changes in skin color, tenderness, or discharge from nipples. Patient reports that she performs routine breast self-exams and denies any abnormalities. Respiratory: Patient reports absence of cough, shortness of breath or breathing difficulties. Cardiovascular: Patient denies chest pain, pressure, or tightness. Peripheral vascular: Patient denies swelling or pain to lower extremities. Genitourinary: Patient denies pain with urination or urinary frequency. Patient reports abnormal bleeding for two weeks that has increased from mild to moderate/heavy flow. Patient denies pelvic pain, cramping, and abdominal pain. Reports that she changes her pad every two to three hours. She also states that she has a period every two to three months and it lasts for five to six days. Patient denies history of abnormal pap smears and states that her last pap smear was performed last year and was normal. OBJECTIVE DATA: Vital Signs: temperature-36.8, pulse-72, respiratory rate-20, blood pressure-122/68mmHg, height-64inches, weight-Weight-80.9kg, BMI-30.6. This study source was downloaded by from CourseH on :09:31 GMT -05:00 This study resource was shared via CourseH WEEK 11 SOAP NOTE 4 General: Patient appears healthy, clean, and well-groomed. Patient is calm, cooperative, alert, and oriented to person, place, time, and event. HEENT: trachea midline, thyroid gland not visible but able to palpate with swallowing, and lymph nodes not swollen and without noted tenderness. Skin: skin turgor normal with no rashes, bruises, or lesions. Excess hair noted to chin area and the patient’s back. Darkening of skin noted to back of the patient’s neck Chest/Lungs: Lung sounds clear, respirations even and unlabored, chest rises and falls evenly. Heart/Peripheral Vascular: Regular rate and rhythm noted, S1 and S2 auscultated, no S3, gallops, or rubs noted. Swelling and edema absent to extremities. Capillary refill less than three seconds, skin warm and pink, palpable pulses to all extremities. Abdomen: abdomen soft, no rebound tenderness noted. Positive bowel sounds in all four quadrants. No lumps or masses noted. Genitourinary: Vaginal examination performed. Moderate bleeding present to vaginal area. Pelvic area negative for masses, lumps, nodules, cervical motion tenderness, or any other abnormal findings. ASSESSMENT: 1. Polycystic Ovarian Syndrome (PCOS): A disorder of the endocrine gland which is the most common cause of infertility. Women with PCOS may experience heavy bleeding with menses, amenorrhea, oligomenorrhea, obesity, and androgenic features such as acne, hirsutism, and male-pattern hair loss (Lucidi, 2018). This diagnosis is most likely due to This study source was downloaded by from CourseH on :09:31 GMT -05:00 This study resource was shared via CourseH WEEK 11 SOAP NOTE 5 presence if hirsutism, irregular periods, heavy bleeding, and obesity. This patient could possibly be experiencing infertility due to not being able to conceive in past attempts. 2. Endometrial hyperplasia (EH): a disorder of the endometrium that results from excess reproduction of cells in the endometrium or the innermost lining of the uterus. Signs and symptoms of EH includes menstrual bleeding that lasts longer than normal, bleeding that is heavier than normal, menstrual cycles that are less than 21-days, and vaginal bleeding after menopause (American Academy of Family Physicians, 2017). The patient is experiencing bleeding that is heavier than normal but her menstrual cycles are greater than 21 days. In addition, the patient is not menopausal. This diagnosis is not likely. 3. Endometriosis: occurs when tissues, glands and stroma that are common found in the uterine lining develops outside of the uterus (Office on Women’s Health, 2018). Signs and symptoms may include irregular bleeding, heavy menstruation, dysmenorrhea, pelvic pain, urinary frequency, nausea, vomiting, or bloating (Davila, 2016). This diagnosis is least likely due to absence of symptoms including pelvic pain, urinary frequency, nausea or vomiting, and bloating. Primary Diagnosis: PCOS PLAN: Labs & Tests: Hemoglobin (14.0 g/dL), Hematocrit (37.4%), Thyroid test panel (normal), Hgb A1C (5.2%). Pharmacological Therapies: Start norgestimate/ehtinyl estradiol 0.25mg/35mcg by mouth once a day. This study source was downloaded by from CourseH on :09:31 GMT -05:00 This study resource was shared via CourseH WEEK 11 SOAP NOTE 6 Education: Patient encouraged to lose weight to help improve symptoms of PCOS. This can be achieved through eating healthy and exercise. Weight loss is considered first-line therapy for PCOS management (Lucidi, 2018). Referrals & Consultations: No indication for referrals or consultations. Follow Up: Notify office if symptoms do not improve within one week. Health Promotion: Patient encouraged to have a pap smear at least once every three years to screen for cervical cancer or abnormalities (Centers for Disease Control and Prevention, 2018). Beginning at age 40, mammograms are recommended every two years. In addition, breast self-exams are to be performed once a month to assess for abnormal findings such as nodules or masses (U.S. Preventive Services Task Force, 2016). Disease Prevention: Patient encouraged to participate in physical activity for at least 30 minutes most days of the week and to eat more fruits, vegetables, lean meats, and refrain from drinking sugary drinks to prevent development of heart disease (American Heart Association, 2015). Holistic Care: • GERD: continue Protonix 40mg daily. • Insomnia: diphenhydramine 25mg, 1-2 tabs at bedtime as needed. REFLECTION: This experience has provided the opportunity to assess and identify signs and symptoms of PCOS and gain an understanding on treatment and management of symptoms. I was provided the opportunity to develop and rule-out differential diagnoses based on presenting symptoms and collected information. I was able to apply pattern recognition with PCOS gained from the course readings and prior patients which enhanced my knowledge base. This knowledge will be used This study source was downloaded by from CourseH on :09:31 GMT -05:00 This study resource was shared via CourseH WEEK 11 SOAP NOTE 7 for diagnosis and management of PCOS in my future career. I agree with the methods used by my preceptor to diagnose the patient with PCOS and the prescribed treatment plan. My preceptor followed recommended guidelines and treatments for PCOS, so no alterations in treatment plans are indicated.