Chat with us, powered by LiveChat Patient complains that she has always been very irregular with her menstrual cycles, and that she never knows when to expect it. She further explains that she sometimes does not have a cycl - Wridemy Bestessaypapers

Patient complains that she has always been very irregular with her menstrual cycles, and that she never knows when to expect it. She further explains that she sometimes does not have a cycl

Please reply to the following discussion with one or more references. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite resources in your responses to other classmates.  

Responses must consist of at least 350 words (not including the greeting and the references), do NOT repeat the same thing your classmate is saying, try to add something of value like a resource, educational information to give to patients, possible bad outcomes associated with the medicines discussed in the case, try to include a sample case you've seen at work and discuss how you feel about how that case was handled. Try to use supportive information such as current Tx guidelines, current research related to the treatment, and anything that will enhance learning in the online classroom.

References must come from peer-reviewed/professional sources (No WebMD/Mayo Clinic or Wikipedia please!).

Discussion attached

Thanks

Jessica Alper

SOAP NOTE FOR PCOS

Name:  J. Q. 

Date: 11/20/2022

Time: 09:15am

 

Age: 23

Sex: Female

SUBJECTIVE

CC:  

“My menstrual cycle is very heavy and painful, and sometimes I don’t have a period at all”

HPI:  Use OLDCART acronym

Patient complains that she has always been very irregular with her menstrual cycles, and that she never knows when to expect it. She further explains that she sometimes does not have a cycle for about 3 or 4 months, and when she finally has a cycle, the bleeding lasts for 7-9 days and it is very heavy and painful. She states she saturates about 6 to 8 pads per day during the first 6 days, until it finally starts getting lighter. She gets very bloated and nauseous during her cycle as well. Has recently not had a period in 2 months. She takes 600mg of ibuprofen 3 to 4x a day with slight relief. States she also uses a heat pad  to her lower stomach during her cycle to help alleviate the pain. 

Medications:  (list with reason for med) write medicine the same way you write a Rx)

· Multivitamins 1 PO QD for immune system

· Zoloft 50mg 2 PO QD for depression

· Buspirone 7.5mg 1 PO BID PRN as needed for anxiety

PMH (list approximate year of Dx of the disease or when surgical procedure performed)

Allergies: NKDA, denies food allergies

Medication Intolerances: Denies

Chronic Illnesses/Major traumas: Anxiety (2017), depression (2017)

Hospitalizations/Surgeries: Wisdom teeth (2019)

 

Family History (list immediate family, age, disease, and whether is dead or alive)

States that her mother (45) recently moved here from Texas, and she lives close by. Her mother has hypothyroidism, hypertension, and diabetes and takes all her medications as prescribed. No cancers on maternal side. She never met her father and is unsure of any family history on his side. 

Social History

General: Born and raised in Texas but moved to FL to start college in 2018. 

Marital status: Single, has a boyfriend of 2.5 years.

Living situation: Lives in an apartment with her current boyfriend who attended the same college. 

Children: No children.

Occupation: just started teaching at an elementary school.

Leisure patterns: she states she does not have much leisure time since she started her new job and is a new teacher. She takes a lot of her work back home to finish the tasks she did not finish at work. 

Social habits: Denies smoking. Drinks occasionally when she goes out with her friends. She used to exercise regularly but she no longer has time for it. Sometimes she tries to go in the weekend, but it does not always work out that way. 

Spirituality: Does not practice any religion.

Nutrition: Eats a lot of fast cheap meals. She and her boyfriend order a lot of food for pick up because neither of them has time to cook. 

Sleep patterns: She usually sleeps 6-8 hours per night but states she is often tired.

ROS (Start each sentence with words such as “Denies, admits, complains, reports”, do not use the words “No, positive for, negative for”. Do NOT list physical exam findings here. If the body system not assess write “Non-Contributory”

General 

States there have not been any changes in the past 5 years. He has been wearing the same size of clothes for the past 5 years. Denies weakness, fatigue, or fever.

Head: Denies headache, head injury, dizziness, or lightheadedness.

Cardiovascular

Denies any troubles with her heart, rheumatic fever, or heart murmurs. Denies having chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema. Has never had EKG done.

Skin

Denies rashes, lumps, sores, itching, and changes in color. Denies changes in his nails or hair. Denies changes in size or color of moles.

Respiratory

Denies cough, sputum, hemoptysis, dyspnea, wheezing, or pleurisy. Has not had a Chest X Ray done. Denies having asthma, bronchitis, emphysema, pneumonia, or tuberculosis.

Eyes

Denies any changes in her vision. Does not use glasses. Last eye exam 2.5years ago (Oct 2020 ). Denies any pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma or cataracts. 

Gastrointestinal

Denies trouble swallowing, heartburn, changes in appetite, or nausea. States she has bowel movements every other day normally, the stools are small, brown and formed. Denies pain or bleeding with defecation. No changes in bowel habits. Denies black or tarry stools, hemorrhoids, constipation, or diarrhea. Denies abdominal pain, food intolerance or excessive belching or passing gas. Denies jaundice, live, or gallbladder trouble. Denies Hepatitis. Does not remember if she has received Hep B vaccine.

Ears

States she doesn’t have any hearing problems. Denies tinnitus, vertigo, earaches, infection, or discharge. Denies use of hearing aides. 

Genitourinary/Gynecological

Goes to the bathroom 4 or 5 times a day. Denies polyuria, nocturia, urgency, burning or pain during urination. Denies hematuria, urinary infections, kidney or flank pain, kidney stones, urethral colic, suprapubic pain, or incontinence. No changes in bladder habits.

Menarche at age 12. States she rarely has periods and when she does, the flow is very heavy and very painful for 7 to 10 days or so. She sometimes bleeds between periods but says it’s more like spotting. She uses 600mg Ibuprofen TID with only slight relief. She saturates about 6 to 8 pads per day. 

LMP: September 2nd. Denies PMS. Denies any vaginal discharge, dyspareunia, itching, sores, lumps, or STDs. G0 P0. Sexually active and uses condoms. Has had one partner in the past 2.5 years. Not currently looking to get pregnant. Denies exposure to HIV infection or STDs.

Nose/Mouth/Throat

Pt states she gets occasional allergies and colds that cause her to have stuffiness and discharge. Denies hay fever, nose bleeding, or sinus trouble. Throat: States her teeth are yellow and sometimes her gums would bleed. Denies use of dentures. Last dental examination 2 yrs ago (Oct 2020). Denies sore tongue, frequent sore throats or hoarseness. Denies having dry mouth or excessive thirst.

Neck: Denies swollen glands, goiter, lumps, pain, or stiffness in the neck.

Musculoskeletal

Denies muscle weakness, paresthesia, loss of sensations, no severe or progressive neurological deficit in lower extremity. No Hx of cancer, or risk factors for spinal infection (no IV drug abuse, UTI, Immune suppression). Denies other muscle or joint pain, stiffness, arthritis or hx of gout. Denies fever, chills, rash, anorexia, weight loss or weakness.

Breast Denies lumps, pain, discomfort or nipple discharge.

Neurological

Denies changes in mood, attention or speech. Denies changes in orientation, memory, insight, or judgment. Denies headaches, dizziness, vertigo, fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements.

Heme/Lymph/Endo Denies anemia, easy bruising or bleeding, and past transfusions. Denies excessive thirst and hunger. Denies thyroid trouble, heat or cold intolerance, excessive sweating, polyuria or changes in shoe size. Denies weight changes or fever.

Peripheral Vascular: Denies leg cramps, varicose veins, past clots in veins, swelling in calves, legs or feet. Pt states there have not been any changes in the color of her fingertips or toes during cold temperatures/weather. Denies any swelling or tenderness.

Psychiatric

Denies nervousness, tension, or memory changes. Admits to anxiety and depression and takes her Zoloft and Buspirone as prescribed 

OBJECTIVE- this is where you document physical exam findings, do NOT use the word NORMAL to document a finding, and instead explain what normal is. For example, the gait is not normal, the gait is steady. If the body part not assessed then type “Deferred”.

Weight  175lbs        BMI 32

Temp 98.3

BP 128/82

Height 5’2”

Pulse 74

Resp 16

General Appearance Skin warm and dry w/o discoloration or pallor, A/O x 3, appropriate responses, cooperative, appears concerned w/o signs of acute distress.

Skin Skin is warm, pink and supple, no lesions noted. Nigricans acanthosis noted on back of the neck. Hair noted on lower cheeks, chin, and neck to the bilateral clavicle. Hair also noted in between the breasts and all over the stomach.

HEENT

Normocephalic, PERRLA, EOMs intact, fundoscopic: red reflex present, no nicking or hemorrhage. TM intact bilaterally, pearly with + light reflex. Nares patent, neck supple. Pharynx: swallows w/o difficulty, no erythema; Neck: thyroid non palpable, no carotid bruits.

Cardiovascular

Carotid upstrokes are brisk, w/o bruits. The PMI is tapping, 7cm lateral to the midsternal line in the 5th intercostal space. S1 louder than S2 on auscultation. No murmurs or extra sounds. Extremities are warm and w/o edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+ , brisk, and symmetric

Respiratory

Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or ronchi.

Gastrointestinal

Abdomen is rounded with active bowel sounds in all four quadrants. It is soft and non-tender; no masses or hepatosplenomegaly. No CVA tenderness.

Breast

Deferred

Genitourinary

 Deferred

Musculoskeletal

No joint deformities. Positive ROM in hands, wrists, elbows, shoulders, knees and ankles. Gait/Posture: Stable gait. Heel and toe walking intact. Spinal column: No kyphosis, scoliosis or lordosis; No noted major motor weakness on knee extension, ankle plantar flexors, evertors, dorsiflexors. No CVA Tenderness.

Neurological 

Cranial nerves II to XII intact. Good muscle bulk and tone. Strength 5/5 throughout. Rapid alternating movements and point to point movements are intact. Gait stable. Pinprick, light touch, position sense, vibration, and stereognosis intact, Romberg negative. Reflexes 2 + and symmetric with plantar reflexes down going

Psychiatric

Alert, relaxed and cooperative. Thought process is coherent. Oriented to person, place and time.

Lab Tests (lists any tests ordered and status of the test, if a rapid test was done at the office, list the results)

· Hemoglobin A1C -  Pending

· Thyroid panel –  Pending

· Serum free testosterone and total –  Pending

· Prolactin –  Pending

· DHEA-S –  Pending

· Anti-Mullerian hormone -  Pending

Special Tests (List any imaging study or special test ordered and status of the test, if the result is available, write the result)

None

 Diagnosis

 Differential Diagnoses with ICD 10 codes (these are Dx you considered, but then ruled out)

· 1- Hypothyroidism – E03.9: fatigue, loss of energy, lethargy, weight gain, decreased appetite, depression, emotional lability, forgetfulness, constipation, blurred vision, and hoarseness. It may also lead to impaired fertility, as well as having heavy or irregular menstrual periods

· 2- Cushing’s disease – E24.9: Elevated levels of cortisol. Symptoms include weight gain, fat deposits, acne, elevated blood sugar, depression, irregular menstrual periods, extra facial and body hair, and more (Nguyen, 2022). 

· 3 – Ovarian hyperthecosis – E28.8: Signs and symptoms similar to PCOS symptoms. Hirsutism, virilization, abnormal menses, obesity, hypertension, and insulin resistance.

Diagnosis with ICD 10 Code

· Polycystic Ovarian Syndrome (PCOS) – E28.2

· Persistent with anovulation and androgen excess. Criteria for this diagnosis include oligomenorrhea and/or anovulation clinical and/or biochemical signs of hyperandrogenism (described as hirsutism and elevated free testosterone) and polycystic ovaries observed by ultrasonography (Barbieri & Ehrmann, 2022). Two of the three criteria need to be met for the patient to be diagnosed with PCOS per the Rotterdam criteria.

CPT Code/Office visit code: 

 

Plan/Therapeutics

Plan:  

· Diagnostic: Pelvic/Transvaginal ultrasound within the next week

· Therapeutic:

· Pharmacological – 

· Start taking Loestrin 1mg/20mcg 1 PO QD, to be taken at the same time everyday

· Non-pharmacological – 

· May do acupuncture therapies

· Exercising 3 to 4 times a week of moderate activity

· Patient education: 

· Low carbohydrate diet and exercise is recommended to lower BMI. This will help in reducing the insulin resistance and insulin levels, which will then decrease the testosterone secretion. The recommended weight loss is between 5-10% of body weight. 

· Different options for hirsutism are available. One option is Vaniqa cream, which may be beneficial to slow down hair growth. Another option is laser hair removal or electrolysis

· Continue practicing safe sex to prevent STIs

· Referral: None at this time – waiting for lab results 

· Follow-up: Follow up in 3 months to see if the birth control pill has helped regulate cycles

·

 

 

References

Barbieri, R. L., & Ehrmann, D. A. (2022). Patient education: Polycystic ovary syndrome (PCOS) (Beyond the basics). UpToDate.  https://www.uptodate.com/contents/polycystic-ovary-syndrome-pcos-beyond-the-basics#H5

Nishioka, H., & Yamada, S. (2019). Cushing's Disease. Journal of clinical medicine, 8(11), 1951.  https://doi.org/10.3390/jcm8111951

Nguyen, H. C. (2022). Endogenous Cushing syndrome. Medscape.  https://emedicine.medscape.com/article/2233083-overview

Orlander, P. R. (2022). Hypothyroidism clinical presentation. Medscape.  https://emedicine.medscape.com/article/122393-clinical

Saslow, L. R., & Aikens, J. E. (2020). Lifestyle interventions for polycystic ovary syndrome: Cross-sectional survey to assess women's treatment and outcome preferences. JMIR Formative Research, 4(9), e17126-e17127.  https://doi.org/10.2196/17126

Shah, S., Torres, C., & Gharaibeh, N. (2022). Diagnostic Challenges in Ovarian Hyperthecosis: Clinical Presentation with Subdiagnostic Testosterone Levels. Case reports in endocrinology, 2022, 9998807.  https://doi.org/10.1155/2022/9998807

Toosy, S., Sodi, R., & Pappachan, J. M. (2018). Lean polycystic ovary syndrome (PCOS): An evidence-based practical approach. Journal of Diabetes and Metabolic Disorders, 17(2), 277-285.  https://doi.org/10.1007/s40200-018-0371-5

Witchel, S. F., Oberfield, S. E., & Pena, A. S. (2019). Polycystic ovary syndrome: Pathophysiology, presentation, and treatment with emphasis on adolescent girls. Journal of the Endocrine Society, 3(8), 1545-1573.  https://doi.org/10.1210/js.2019-00078

 

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