NRNP 6552 Week 4 Case Study Discussion Common Gynecologic Conditions, Part 1 – Missing Period Gynecologic Focused SOAP Note

NRNP 6552 Week 4 Case Study Discussion Common Gynecologic Conditions, Part 1 – Missing Period Gynecologic Focused SOAP Note Patient Information: Initials: E.G. ; Age:38; Sex: Female; Race: Caucasian S. CC: “I am here to discuss contraceptive options.” HPI: E.G. is a 38 y/o Caucasian female who came into the office to discuss contraceptive options. She has a new partner who has not fathered a child, but E.G. is no longer interested in having children. She has six children of her own (G5P5006). Her past medical history is remarkable for exercised-induced asthma, migraine, and IBS. She denies alcohol, tobacco, and drug use. Current Medications: 1) vitamin C one tab PO daily 2) Albuterol inhaler two puffs TID PRN for cough-last dose two months ago. 3) Acetaminophen (Tylenol) 325 mg, two tabs q 4-6 hr PRN for headache Allergies: No known drug, food, or environmental allergies. PMH: 1) Exercised-induced asthma, currently controlled. 2) Migraine – takes Acetaminophen as needed 3) IBS – diagnosed when she was 25 y/o. Currently controlled with diet. No meds. Immunizations: She is up-to-date with her vaccines, including Pfizer Covid vaccine X2 and booster dose X1. The last Tdap vaccine was five years ago. PSHx: Tonsillectomy when she was a child; no hospitalizations other than childbirth. Social Hx: Denies any alcohol or tobacco use. Denies recreational drug use. She works as a case manager at a community hospital. She does not text or drive and always uses a seatbelt when driving. She lives in a single-story home with her children and her partner. All family members are insured through her employer. She exercises for 30 minutes twice a week using the treadmill at home. She watches what she eats due to her IBS. She does not consume more than two caffeinated beverages a day. Fam Hx: • Mother is alive with osteopenia and fibromyalgia. • Father is alive with a history of skin cancer (basal cell). • Maternal grandmother is alive with dementia. • Maternal grandfather is alive with COPD. • Paternal grandparents are both deceased due to an automobile accident. • Older sister and one younger brother, both with no reported medical problems. • All her six children are healthy. Mental Hx: She denies any mood swings, depression, or anxiety. She states that she has some stress balancing family and work. Violence Hx: She has no issues or concerns about safety. She feels safe at home. Reproductive Hx: She had menarche at the age of 13. Her LMP was a week ago. Her menses regularly occur between 26-28 day cycles, with moderate flow, no accompanying symptoms, and lasting about three days. She is G5P5006. Her children's ages are 15 y/o, 13 y/o, ten y/o, six y/o, and two y/o twins. She has no complications during pregnancy and childbirth. She and her partner do not consistently use a condom. She has never used any OCP in the past. She denies any sexual concerns and only does the vaginal type of intercourse. She has no history of STI, and her partner was tested for STI a month ago. The results are negative. ROS: GENERAL: Denies weight loss, fever, chills, weakness, or fatigue. • HEENT: Denies any dizziness, blurred vision, or hearing loss. Reports occasional migraine headache relieved by Tylenol. Denies any congestion, runny nose, or sore throat. • CARDIOVASCULAR: Denies any chest pain, palpitations, or chest discomfort. • RESPIRATORY: Denies any SOB or dyspnea on exertion. Reports using Albuterol as needed for her asthma. Denies any recent cough or respiratory infection. • GASTROINTESTINAL: No abdominal pain. Denies any nausea and vomiting, diarrhea, or constipation. • NEUROLOGICAL: Denies syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. • MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, or stiffness. • HEMATOLOGIC: Denies anemia, easy bleeding, or bruising. • LYMPHATICS: Denies any swollen glands—no history of splenectomy. • PSYCHIATRIC: No history of depression or anxiety. • ENDOCRINOLOGIC: Denies any unusual sweating, heat, or cold intolerance. No polyuria or polydipsia. GENITOURINARY/REPRODUCTIVE: Denies any burning on urination. Denies any unusual vaginal discharge. Sexually active and denies pain during intercourse. She has not done a mammogram; her last pap test was two years ago. She received her HPV vaccine when she was 16 y/o. O. General: This is a 38 y/o Caucasian female who appears her age. Alert and conversant, not in acute distress. She is a good historian, and her affect is appropriate for the situation. VS: T-98.40 F, HR- 68 RR- 20, BP- 118/72 Height 5’ 7” (67 inches), Weight 148 lb (67.2 kg), BMI 23.1 • HEENT: Head is atraumatic, normocephalic. PERRLA. TM intact bilaterally. The neck is supple without adenopathy. • Lungs/CV: Breath sounds are clear in all lung fields; no adventitious sound noted. Heart is RRR, no murmur. • Breast: soft, fibrocystic changes bilaterally, without masses, dimpling, or discharge • Abdomen: soft, non-tender, +BS in all quadrants • VVBSU: No inflammation, irritation, lesions, or discharges noted. First-degree cystocele noted. • Cervix: firm, smooth, parous, without CMT (cervical motion tenderness) • Uterus: RV(retroverted) mobile, non-tender, approximately 10 cm. • Adnexa: without masses or tenderness Diagnostic results: 1) Urine pregnancy – before starting a patient on any contraception, patients need to be screened for contraindications such as suspected or known pregnancy (Cooper et al., 2022). 2) Blood work – CBC, CMP, Lipid profile -hormone contraceptives may impair glucose intolerance and is usually dose-dependent (Cooper et al., 2022). 3) Pap test and mammogram – ensuring that annual women's screening tests are done will ensure baseline data before starting any contraception. 4) Prescribers should monitor baseline weight and BMI before initiating th