Common Health Conditions with Implications for Women DQ
Common Health Conditions with Implications for Women DQ
Select a patient that you examined during the last four weeks as a Nurse Practitioner. Select a female patient with common endocrine or musculoskeletal conditions, Evaluate differential diagnoses for common endocrine or musculoskeletal conditions you chose .With this patient in mind, address the following in a SOAP Note:
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Subjective: What details did the patient provide regarding or her personal and medical history?
Objective: What observations did you make during the physical assessment?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up appointment with the provider, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation? And how can you relate this to your class and clinical readings.
Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.). Burlington, MA: Jones and Bartlett Publishers.
Chapter 22, “Urinary Tract Infection in Women” (pp. 535–546)
Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.
Review: Chapter 8, “Primary Care in Women’s Health” (pp. 431–560)
Centers for Disease Control and Prevention. (2012b). Women’s health. Retrieved from http://www.cdc.gov/women/
National Institutes of Health. (2012). Office of Research on Women’s Health (ORWH). Retrieved from http://orwh.od.nih.gov/
U.S. Department of Health and Human Services. (2012a). Womenshealth.gov. Retrieved from http://www.womenshealth.gov/
Chief Complaint: “I have increased coarse body hair, irregular periods, and pelvic pain for the past one year”. Comment by Erica Gifford: Great CC
History of Present Illness: FJ is a 23-year-old G0P0 African American obese female who presented to the clinic with complaint of increased coarse body hair; irregular periods, and pelvic pain for the past one year. FJ reported that she noticed weight gain, especially around her waist; increased hair growth on her chest, chin, lips, stomach, back, thumbs, and toes; and oil skin, acne, and dandruff. Patient also reported that she used to have quite regular period, but for the past one year, she skips periods two to four months before her next menstrual cycle. Patient reported that she wants to get pregnant, but she has never been pregnant. Patient reported breast pain and lower abdominal/pelvic pain. She also reported that she got married last years, and she started monitoring her ovulation with an over the counter ovulation kit. She noticed that she does not ovulated for the past one year since she started checking. Patient reported that she has skin tags, such as excess skin on her armpits and neck area. She is sad because of the reported symptoms and not being able to conceive. She decided to see an obstetrics and gynecologist for an evaluation and treatment. Patient denied fever, chills, nausea, vomiting, diarrhea, or constipation.
Location: Pelvic, lower abdominal, uterus, skin, and breast.
Duration: One year
Quality: Pelvic/lower abdominal pain; breast pain; increased skin growth.
Severity: 7/10 on pain scale
Timing/Onset: One year ago. Common Health Conditions with Implications for Women DQ
Alleviating Factors: Pain medication and heating pad.
Aggravating Factors: None
Relieving Factors: Ibuprofen pain medication and heating pad.
Treatments/Therapies: Over the counter ibuprofen pain medication, and heating pad.
Medications: Motrin 200-400 mg orally every 6 to 8 hours as needed for pain.
Allergy: No known drug or food allergy.
Past Medical History: None
Past Surgical History: None
GYN History: LMP 07/15/2016; last Pap smear 2/20/2015: negative; menarche 12; cycle: 5 days, but irregular; age of first intercourse 18 year; sexual active and heterosexual with only one sex partner; no birth control measures.
OB History: Gravida: 0 Para: 0
Personal/Social History: Married; college graduate; employed; lives at home with the husband; denied alcohol abuse, tobacco abuse or illicit drug abuse.
Immunizations: Flu vaccine 11/24/16; no pneumococcal shot.
Family History: Father: Diabetes, hyperlipidemia, BPH, hypertension; Mother: hypertension, diabetes. Siblings alive and well.
Review of Systems:
General: Positive weight gain; no fever, no night sweats, no chills, no fatigue, or no weakness.
Head: Admitted dandruff, denied dizziness, migraine or headache.
Eyes: Denied visual problem
Chest: no chest pain, cough, SOB
Heart: No palpitation, no irregular heartbeat
Breast: Admitted breast pain; no erythema, inflammation or nipple discharge.
Gastrointestinal: Reported lower abdominal pain; central obesity; increased waist fat; denied nausea/vomiting, constipation, or diarrhea.
Urinary: denied urinary tract infection or problems; no dysuria or urinary frequency.
GYN: Reports pelvic pain, irregular periods, difficult getting pregnant, no ovulation, skipped periods 2 to 4 months before her next menstrual cycle; no menorrhagia, no vaginal bleeding or discharge.
Musculoskeletal: denied pain radiation, muscle or joint pain.
Skin: reports acne, oily skin, increased coarse hair growth on chest, stomach, back, thumbs, and toes. Patient reported skin tags like excess skin on armpit and neck.
Psychiatry: No mental health problems; mood changes, depression or anxiety. Common Health Conditions with Implications for Women DQ
Neurological: denied dizziness, weakness, or seizures.
Endocrine: No thyroid problem, no diabetes, no hot/cold intolerance.
Immunologic: No recurrent infections or immune deficiencies.
Hematologic: No cancer, anemia, blood transfusion or bleeding disorder.
General: Patient is obese, pleasant, alert/oriented, and answers questions appropriately. No acute distress.
Vital signs: T 37.0, B/P 125/76, P 68; RR 16; SPO2 100% RA. Weight 182 pounds, BMI 30.3, Height 5ft 5in. Weight reflected 15 pounds increase from what the patient reported was the last weight last 4 months.
HEAD: Atraumatic, normocephalic; scalp: + dandruff.
Neck: supple, excess skin fold, no lymphadenopathy, no thyromegaly.
Chest/Lungs: Increased coarse chest hair noted; non-labored breathing; clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen/pelvic: lower abdomen/pelvic tenderness, enlarged multiple ovaries noted, obese, waist circumference >35; waist-to-hip ratio > 0.85; upper/lower abdominal hair.
Back: increased upper back hair noted, Normal curvature.
Skin: Increased coarse hair noted on the chin, lips, chest, upper/lower abdomen, upper back, thumbs, toes. Oily skin, acne, skin tags like excess skin on armpit/neck, and acanthosis nigricans noted on neck and armpits.
Breast: + pain/tenderness; no redness, swelling or discharge.
Genitals: External genital normal, except clitoris that is enlarged, vagina pink, and cervix closed; no rash, redness or discharge. Comment by Erica Gifford: What about uterus size any tenderness? Bimanual exam?
Lab Test and Results:
Pregnancy urine tests for human chorionic gonadotropin (hCG): negative, blood tests like testosterone/androgen test: high/abnormal; Prolactin test: level high/abnormal, + infertility; cholesterol/triglycerides blood test: abnormal; TSH test: normal rule out under/over active thyroid; hydroxyprogesterone: normal ruled out adrenal problem. Glucose tolerance/insulin levels: + insulin resistance. Luteinizing hormone concentration/follicle–stimulating level test: Elevated.
Vaginal ultrasound (sonogram): + multiple cysts in the ovaries; thicker endometrium lining.
1. Polycystic Ovarian Syndrome
2. Cushing Syndrome
3. Premature Ovarian Failure
Polycystic Ovarian Syndrome (PCOS): Women’s Health (WH, 2014) described polycystic ovarian syndrome as an imbalance of woman’s sex hormones estrogen and progesterone, which causes development of ovarian cysts and irregular or absent menstrual cycle in women. Also, the hormonal imbalance leads to fertility, cardiac function, blood vessels, hormones, and appearance problems. According to WH (2014), Women with PCOS usually have elevated levels of male hormones (androgens); missed or irregular periods; multiple little ovarian cysts; hirsutism like increased hair growth on the face, chest, stomach, back, thumbs, or toes; acne, oily skin, or dandruff; weight gain or obesity, usually with extra weight around the waist; pelvic pain; anxiety or depression; and sleep apnea. Diagnosis of PCOS according to WH (2014) is based on acne and/or hirsutism; infertility due to anovulation; abdominal obesity; endocrine abnormalities based on laboratory tests; elevated androgen/testosterone level; positive insulin resistance; elevated luteinizing hormone concentration; follicle–stimulating level; multiple cysts in the ovaries; thicker endometrium Common Health Conditions with Implications for Women DQ
Polycystic ovarian syndrome is selected as the primary diagnosis because the patient’s clinical presentations; laboratory tests; and sonographic evaluations as aforementioned confirmed the diagnosis of polycystic ovarian syndrome. In fact, the results of the laboratory tests, radiologic evaluation; physical examination; and clinical presentation as aforementioned are all synonymous with the recommended clinical guideline for diagnosis of the PCOS. Comment by Erica Gifford: Excellent primary diagnosis
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