Assignment Task:
Jennifer
Barbara is 48-year-old female who complains her menstrual cycle has recently become irregular, and she is experiencing hot flashes and vaginal dryness. She has also noticed a decrease in her desire for sex lately. She has been married to a man for 20 years, is in a stable relationship, and has two daughters ages 16 and 18. She is otherwise healthy with an unremarkable medical history. Her pregnancy test is negative. Her Pap smear and STI panel are all negative.
Problem-Focused SOAP Note Format
Subjective:
Chief Complaint (CC): "I have been having irregular menstrual, decreased desire for sex and a lot of hot flashes."
History of Present Illness (HPI): 48-year-old female arrives to clinic with complains of recent irregular menstrual, hot flashes, and has a decrease in her desire for sex lately. She has been married to a man for 20 years, is in a stable relationship, and has two daughters ages 16 and 18. She is otherwise healthy with an unremarkable medical history. Her pregnancy test is negative. Her Pap smear and STI panel are all negative.
Past Med. Hx (PMH): No significant PMH. Denies any hospitalization, surgical problems, allergies to food or drugs. No past history of STI.
Immunization: Up to date, has HPV two dose done. Flu vaccine on 08/05/2024. COVID booster 10/13/2021.
Family Hx:
Mother, 78, alive, DM II, HTN
Father, 70, alive, HTN
Sister, 45, alive, no health problems
Maternal Grandmother, 81, deceased, HTN, GERD
Maternal Grandfather, 75, deceased, heart attack
Paternal Grandmother, 83, deceased, natural causes
Paternal Grandfather, 63, deceased, HTN, HLD
Social Hx: She has been married for 20 years, in a stable relationship. She has two daughters 16 and 18 that live with her and her husband. She denies any alcohol, or drug usage. She denies smoking. She likes to walk her dogs daily in the evening with her husband every night. She is a stay at home mom. She cooks a variety of meals for her family. Practices safe sex with her husband consistently.
Review of Systems (ROS)
Constitutional: (-) pain, chest pain, fever, weight loss, night sweats, chills, and changes in sleep. (+) night sweats, hot flashes, decreased sex drive, feels more forgetful, sleep disturbances. When did you start developing these symptoms? How often do you have hot flashes/ night sweats? Are there any identifiable causes of you having a lower sex drive?
HEENT: Do you have any changes in smell? (-) sore throat, cold sores, difficulty swallowing, headache, dizziness, vision changes, hearing changes, nasal congestion, sinus pain or rhinorrhea, neck tenderness, no changes in sense of smell
Breast: (+) Tenderness, slight asymmetry noted (-) drainage, nodules, dimpling, or masses
Lungs: (-) SOB, pain, cough or wheezing, sputum production, prior tuberculosis, pleurisy, coughing up blood
Heart: (-) chest pain, dyspnea, edema, palpitations or syncope.
GI: (-) changes in bowel movements, vomiting, stomach pain, blood in stool, or acid reflux.
GU: (+) stress incontinence, urinary frequency. Reports urine is yellow, no hematuria or odor. (-) dyspareunia
Genitalia: (-) pain, odor, or drainage, lesions, vaginal dryness (+) LMP 9/25/24, irregular, 2 pads a day for 1-2 days
Psych : (-) Depression, suicidal ideations, (+) forgetfulness, anxious
Last Eye Exam was January 2024 with no abnormal findings 20/20 vision,
Received Flu vaccine in 08/2024
Dental exam done in November, 2024, had dental cavities that were filled.
Last physical exam was January 2024
Up to date on all Immunization: had HPV 2 doses already
Objective:
VS: BP: 122/80, HR 65, RR:16, TEMP 98.6, O2 SAT: 100% HT: 62.4 inches WT: 133lbs BMI: 23.77 (Normal)
Negative Pregnancy Test, Negative STI Panel, Pap smear - Neg
General: 48 y/o female, AAOx4, interactive and answers appropriately. Well developed, and nourished. Appears stated age. Patient appropriately dressed for event.
HEENT: NC/AT, PERRL, EOMI, good conjugate gaze, Nares patent bilaterally, no sinus pain or pressure, MMM, oropharynx without erythema, no exudate from throat, Tonsils 1+. neck is Supple, Normal ROM, no lymph node swelling, no masses noted.
Lungs: Normal respiratory effort, even and unlabored, CTAB, no cough, wheezing or rhonchi present
Heart: RRR, normal s1/s2, no m/r/g, no edema
Abdomen: Flat with no visible masses or pulsations on inspection. Soft, non-distended, normal BS x 4, no masses, hernia, rebound tenderness or guarding. Bowel sounds present and normoactive in all fields. No guarding, tenderness, organomegaly, or ascites. No CVA tenderness.
Psych: (-) Depression, suicidal ideations
Neuro: A&O x4 to person, place, situation, and time. All 12 cranial nerves grossly intact. Normal gait, No antalgic gait present. Negative Romberg test. Lower extremities DTRs +2 and equal bilaterally, negative Babinski reflex.
Breast: without masses, lesions or drainage, R breast slightly larger than L breast.
Genitalia: Normal female external genitalia
Assessment:
Diff dx:
E05.9 Thyrotoxicosis, unspecified
Pertinent Positive: Nervousness, restless, hot flashes, forgetfulness (memory lapses), insomnia, (Hollier, 2021)
Pertinent Negative: thyroid enlargement, tremors, vision changes, exophthalmos (Hollier, 2021)
E28. 2 Polycystic ovarian syndrome
Pertinent Positive: Night sweats, insomnia, mood instability, irregular periods
(Shahid, Iahtisham-Ul-Haq, Mahnoor, Awan, Iqbal, Munir, & Saeed, 2022).
Pertinent Negative: alopecia, hirsutism, deeping of voice (Hollier, 2021)
Final Diagnosis:
N95.1 Menopausal and female climacteric states
Menopause occurs most often in women 45-55 years old. Menopause occurs in 100% of women.
Positive Pertinent information: night sweats, menstrual irregularities, hot flashes, anxiety, forgetfulness, stress incontinence, urinary frequency.
Plan:
Dx Plan: Pregnancy test - Neg, STI panel - Neg, Pap smear-no abnormal findings,
Thyroid panel- in normal range
Per Hollier Dx Studies: Endometrial ultrasound ***
Treatment Plan:
Nonpharmacologic: Kegel exercises, self-breast exam monthly, avoid factors that precipitate vasomotor instability, regular exercise program to promote feeling of well-being and prevention of osteoporosis, low fat high calcium diet, continue maintaining healthy weight. (Hollier, 2021)
Pharmacological: Micronized progesterone 300 mg HS decreases VMS (hot flushes, night sweats). SSRIs used with moderate success for hot flashes in women who are unable/unwilling to use estrogen (Hollier, 2021)
Education:
- Hormone therapy is gold standard and most effective treatment for vasomotor symptoms (Hollier, 2021)
- Menopause is caused by declining ovarian function and occurs most often in women 45- 55 years old (Hollier, 2021)
- Menopause occurs in 100% of women (Hollier, 2021)
- Systemic hormonal therapy does not improve sexual function, sexual interest, arousal or orgasmic response in women without menopause symptoms (Hollier, 2021)
- Vasomotor symptoms are the most common manifestation of the menopause transition and postmenopausal phases of reproductive life (Stuenkel, 2018).
Referral/Follow-up: Endocrinologist if symptoms don't respond to medication therapy and lifestyle changes. Follow up in one month.
Guadalupe
Hillary is a 63-year-old woman G7P7 all uncomplicated NSVDs, complains of inadvertently urinating on herself whenever she coughs, sneezes, or heartily laughs. It has been happening intermittently since the birth of her last 3 children, but it now happens so often that she must wear a sanitary pad, and she is afraid there can be an odor at times. She now also feels "something at the entrance." Upon physical exam, you note that there is an organ about 1cm covering at the 12 o'clock of her vaginal entrance. She asks you what, if anything, can be done to alleviate this that does not have to entail having surgery.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
1. Subjective:
- What other relevant questions should you ask regarding the HPI?
- Have you noticed a vaginal bulge? If yes, have you tried to push it back?
- Have you had lower back pain?
- Have you had pelvic fullness?
- Do you have vaginal pain?
- Do you have urinary urgency? Or hesitancy?
- Do you have pain when sitting for a prolonged time?
- Do you feel that your bladder is still full after you void?
- Do you experience constipation?
- Does this problem interfere with your daily life?
- Have you seen blood in the urine?
- What other medical history questions should you ask?
- Do you have GI disorders?
- Cardiovascular disorders?
- Do you have a history of bladder or kidney disease?
- Have you had any neurological disorders?
- Have you had surgery for urinary incontinence?
- Have you had a hysterectomy?
- What other social history questions should you ask?
- Do you smoke or drink alcohol? Drink caffeine?
- Are you sexually active? Does this problem interfere with your sexual life?
- Do you live alone or with family?
- Do you have a support system?
- Do you have easy access to the bathroom at night?
- How is your living environment?
- What other family history questions should you ask?
- Do you have a mother, sister, aunt, or grandmother that had pelvic organ prolapse?
- Do you have a family history of bladder or kidney disorder?
2. Objective:
- Write a detailed, focused physical assessment on this patient. Want Professional Help?
VS, BMI, And pain and rate assessment.
Explain the physical examination to the patient and ask for consent.
After assessment of cardiac and pulmonary systems, proceed to a pelvic examination. Assess the vulva and vagina. Look for irritation and lesions. Ask the patient to bear down and rest to inspect the introitus and anal sphincter. During the rectal examination, ask if she can squeeze. Then grade it (Alexander et al., 2023).
The speculum examination includes an assessment of vaginal muscle support and defects, vaginal rugae, and observing what part of the organ is prolapsing. Bimanual pelvic examination to assess for tone and contraction (Alexander et al., 2023).
Evaluate the perineal area, sacral, and lower extremities for neurologic deficits. Measure sensory and motor reflexes: knees, ankles, and feet.
Use the POPQ (The International Continence Society system) reference. This patient is +1 prolapse and stage 3 in relation to the vaginal opening (Alexander et al., 2023).
Assess the patient's prolapse severity since she does not want surgery. If urinary obstruction or vaginal damage is found, then surgery is a must (Alexander et al., 2023). The patient has had seven vaginal births, and education on the risks and complications of not having surgery should be addressed (Alexander et al., 2023).
POC: Urine dipstick (Alexander et al., 2023).
- Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.
Diagnostics: Post-void residual measurement, cystometric studies, CBC, urinalysis
3. Assessment/ Diagnosis:
- What is your presumptive diagnosis? Why?
Presumptive diagnosis: Anterior vaginal wall prolapse (N81.1). This prolapse refers to the lower ventral vaginal wall with possible bladder prolapse caused by the muscle dysfunction of the pelvic floor that is not supportive of the organs. This patient is likely to have this type of prolapse due to the position of the bulging. She is at high risk of developing POP due to multiparity with vaginal delivery, older age, and possibly overweight (Epocrates, 2024).
- Any other diagnosis or differential diagnosis you would like to add?
Cervical elongation (N88.4).
Vaginal cyst (N89.8). A vaginal cyst is a lump in the vagina. Dyspareunia and pain with manipulation may be experienced. The patient's assessment is not consistent with the vulvar cyst (Epocrates, 2024).
- What type of incontinence is this patient experiencing?
Stress incontinence. This type of incontinence is provoked involuntarily by coughing, sneezing, laughing, and exertion (Epocrates, 2024). It is common in women with a history of multiple vaginal births.
4. Plan:
- How will you manage this patient? What treatment or medication would you prescribe and why?
The patient is symptomatic. The first treatment that is recommended is a pessary device. These devices are built to be fitted to restore organ position to their normal place (Alexander et al., 2023).
Pelvic floor muscle rehabilitation may also be beneficial for the patient to help toning the pelvic and genitourinary muscles. She also has stress incontinence (Alexander et al., 2023).
- Explain treatment/management guidelines including any possible side effects and/or consideration management of the diagnosis.
Vaginal estrogen can be ordered with pessary device to prevent vaginal erosion and promote lubrication.
Premarin 1 to 2g cream PV at nighttime; or
Estradiol 2 to 4g cream PV nightly one or two times per week (Epocrates, 2024).
- What patient education is important to include for this patient? (Consider including pharmacological, supplements, and non pharmacological recommendations and education)
Educate the patient on the importance of a pelvic muscle exercise routine. If the patient is overweight, losing weight will benefit her; caffeine avoidance and smoking cessation with support should be included if applicable. Also, educate on the need for surgery if there is no improvement from the treatments and if the patient is eligible for surgery (Epocrates, 2024).
- What is the follow-up plan of care?
Follow up in one week to assess the device if the patient agrees to try a pessary device in this visit.
Referral: Urology specialty for consultation
References:
Epocrates. (2024). Urinary incontinence.
FAAN, I.M.A.P.A.A. F. (2023). Women's Healthcare in Advanced Practice Nursing (3rd ed.). Springer Publishing LLC.