NRNP 6552 Common Health Conditions with Implications for Women

Episodic/Focused SOAP Note Template

Patient Information:

BB, 39, F, undisclosed

S.

CC: Positive home pregnancy

HPI: Bonita Bubble is a 39-year-old female presenting today at your clinic with a positive home pregnancy test. She reports breast tenderness, fatigue, and nausea, which made her suspect she is pregnant.

Current Medications:

Woman’s vitamin daily

Allergies:

No known medication, latex, or environmental allergies

PMHx:

Disappearing twin

Ectopic Pregnancy- Treated with methotrexate

Surgical Hx:

C/s for breech after failed version

Soc & Substance Hx:

Patient is a mother of 3.

Fam Hx:

Non-contributory

Mental Hx:

Denies

Violence Hx:

Denies

Reproductive Hx: G42123. LMP 4/24/2023. First  menses age 12. Menstrual cycles every 28 days and lasting for 5 days. Pap and STD history are negative.

ROS:

GENERAL: + Fatigue. Denies weight loss, fever, chills, weakness

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: + Breast tenderness. Denies breast pain or discharge. Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies SOA shortness of breath, cough, or sputum.

GASTROINTESTINAL: + Nausea. No anorexia, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: Denies headache, dizziness, 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, bleeding, or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY: + Breast tenderness. Denies dysuria. No vaginal discharge or pain

ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.

O.

CARDIOVASCULAR: S1 S2 on auscultation, RRR. No carotid bruits. No murmurs, gallops, or rubs. 2+ Radial and pedal pulses bilaterally

RESPIRATORY: Equal chest rise and fall. No nasal flaring. Normal respiratory effort. No rales/crackers/rhonchi

GASTROINTESTINAL: BS present x 4. Abdomen is soft, symmetric, non-tender w/o distention, no masses

ENDOCRINOLOGIC: Thyroid is midline, soft, smooth, symmetrical, non-tender, and slides upward with swallowing.

GENITOURINARY: Generalized bilateral breast tenderness. No pain. No lumps. No nipple discharge.

Diagnostics:

Pelvic ultrasound- confirm pregnancy, determine viability, provide gestational age, and r/o ectopic

Prenatal Panel- to determine the mother’s overall health, check for diseases, or illnesses that could be harmful to the fetus

A.

Primary Diagnosis

Secondary Amenorrhea ICD-10 code N91. 2

Differential Diagnosis

1. Positive pregnancy test (ICD 10 code Z32.01)
2. Normal pregnancy (ICD-10 code 9)
3. Ectopic pregnancy (ICD-10-CM 9)

The most crucial diagnosis for this patient is secondary amenorrhea. Secondary amenorrhea is the absence of a menstrual period for three months or more (Amenorrhea: Absence of Periods, 2020). Amenorrhea is a symptom of several health conditions. However, regardless of the possible cause, the first priority is to rule out pregnancy. According to Nawaz and Rogol (2023), the most common cause of amenorrhea is pregnancy. The patient, in this case, study reports a positive home pregnancy test. As a practitioner, my first priority is to confirm the viability of the pregnancy. A transvaginal ultrasound would confirm pregnancy, and establish the pregnancy’s location, viability, and fetal gestational age (Lee et al., 2022).

Once pregnancy is confirmed, I recommend an ABO Group and RHO(D) Typing to determine the patient’s blood type and establish if she is a candidate to receive Rh immune globulin. A Comprehensive Metabolic Panel (CMP) checks the patient’s kidneys and liver function. A Complete Blood Count (CBC) assists in diagnosing conditions that could cause amenorrhea such as anemia, clotting disorders, or infections. Fetal growth and development are associated with maternal lipid concentrations, therefore a Lipid panel is an important laboratory test. A Thyroid Panel with TSH is necessary to monitor the thyroid’s hormone concentrations and determine if there are any deficiencies. A Human Immunodeficiency virus (HIV) test establishes the patient’s status. A positive woman for this virus can transmit it to the fetus. A Rapid Plasma Reagin (RPR) checks for syphilis which can be fatal to the fetus. The Rubella Antibodies IgG test determines if the patient has immunity to rubella. A mother infected with rubella during pregnancy puts her baby at risk for birth defects. Hepatitis B and C are transmittable viruses to the fetus resulting in complications. The patient is of advanced maternal age. Due to her age, I would also order Noninvasive Prenatal Testing (NIPT). NIPT screening is used to detect congenital abnormalities such as Down Syndrome or Trisomy 13 and determines the gender of the fetus.

Treatment recommendations for this patient include taking a prenatal vitamin with 800 mcg of folic acid. It is unknown when she last had a pap smear. I would recommend that the patient complete this test to determine the health of her cervix. I would advise the patient to avoid any alcohol, no smoking, maintain a healthy diet, regular exercise, and increase her water intake. I would also discuss concerns about any abuse. I would inform the patient to give notice if she develops heavy vaginal bleeding, abdominal or pelvic pain, severe nausea/vomiting, fevers not relieved by Tylenol or headaches that do not subside after a day. 

 

                                                                                            Congratulations You are 12 weeks pregnant!!!!

                                                                                                                    EDD Jan 29, 2024

References

Amenorrhea: Absence of Periods. (2020). Www.acog.org. https://www.acog.org/womens-health/faqs/amenorrhea-absence-of-periods

Lee, W. A., Nelson, G., & Grogan, S. P. (2022). Sonography 1st Trimester Assessment, Protocols, And Interpretation. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK573070/

Nawaz, G., & Rogol, A. D. (2023). Amenorrhea. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482168/#:~:text=There%20are%20primary%20and%20secondary

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:

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.

References

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/

Thanks for sharing your discussion about a positive home pregnancy test. This post is highly informative and thorough. You have highlighted some crucial points. I am in complete agreement with the statement that you have made. You stated that” my priority is to confirm the viability of the pregnancy.” I vehemently believe that this approach will prevent misdiagnosis. Also, the benefits of this approach will facilitate the following: allow healthcare professionals to provide accurate treatment, monitor pregnancy progress, assess the risk of pregnancy, find out gestational age, and provide expectant mothers with guidelines that will aid in the decision-making process regarding family planning and childbirth.

It is crucial to know that the confirmation of pregnancy is done by ordering some diagnostic investigations. In addition to the diagnostic tests you mentioned, I would like to add some tests that might be appropriate and suitable at the different stages of pregnancy. The possible diagnostic tests to confirm pregnancy are Serum Human Chorionic gonadotropin  (HCG) Tes, fetal heart rate monitoring with a Doppler device, and pelvic exam.

It is widespread to use HCG to screen for pregnancy. This qualitative point-of-care test is performed to reduce the negative impact on Maternal Fetal health. A rapid qualitative serum HCG testing will facilitate a 1-hour turnaround time for results. This will help the clinician to provide appropriate treatment (Mattiello & Stickle, 2023).

The well-being of a fetus is assessed by monitoring the fetal rate. A Doppler ultrasound scans the fetal heart rate before and after labor. An ultrasound transducer is placed on the abdomen of the expected mother to monitor the heart rate continuously. On the contrary, a handheld Doppler transducer is used to obtain intermittent measurements (Hamelmann et al., 2020).

Pelvic examination plays an integral role in the patient who presents with intrauterine gestation. This exam provides additional and pertinent information for certain obstetrics conditions. The pelvic examination includes using a speculum and bimanual examination to assess any changes in the cervix and uterus that indicate that a woman is pregnant. This examination also facilitates the collection of cervical cultures (Tucker & Evans, 2019).

In conclusion, confirming the viability of a pregnancy is essential In obstetrics. The various available diagnostic tests will help ensure that the fetus and expected mother receive appropriate treatment.

References

Hamelmann, P., Vullings, R., Kolen, A. F., Bergmans, J. W., van Laar, J. O., Tortoli, P., & Mischi, M. (2020). Doppler ultrasound technology for Fetal Heart Rate Monitoring: A Review. IEEE Transactions on Ultrasonics, Ferroelectrics, and Frequency Control, 67(2), 226–238. https://doi.org/10.1109/tuffc.2019.2943626

Mattiello, C. J., & Stickle, D. F. (2023). Characterization by image analysis of the dose vs response curve for a qualitative serum hcg lateral flow immunoassay. Clinica Chimica Acta, 538, 175–180. https://doi.org/10.1016/j.cca.2022.11.020

Tucker, P., & Evans, D. D. (2019). Are pelvic exams necessary anymore? Advanced Emergency