Where does review of systems go in a soap note

Bethel U. Godwins

Walden University

NURS 6551, Section 8, Primary Care of Women

August 14, 2016

Patient Initials: FJ Age: 23 Gender: Female

SUBJECTIVE DATA:

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.

Radiation: None

Severity: 7/10 on pain scale

Timing/Onset: One year ago.

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.

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.

OBJECTIVE DATA

Physical Exam:

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?

ASSESSMENT:

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.

Differential Diagnosis:

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

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

Cushing Syndrome (CS): The Pituitary Society (PS, 2015) described Cushing syndrome as the condition that occur due to excess cortisol hormone in the body. Cushing’s syndrome is fairly rare, but mostly found in women than men between ages 20 to 40. Signs and symptoms as described by PS (2015) are weight gain, hypertension, irritability, round face, fatigue, menstrual irregularity, poor concentration, poor short term memory, excess hair growth in women, red, ruddy face, and extra fat around the neck. Cushing’s syndrome is also usually associated with moon facies, central fat deposition, bruising easily, decreased libido, stretch marks, sleep disturbance, hypertension, muscle wasting, abdominal striae, buff alo hump, and osteoporosis. Cushing syndrome is ruled out as the primary diagnosis for the patient because the signs and symptoms of CS that are specific to CS alone, such as buff alo hump, stretch marks, easily bruise, decreased libido, moon face, and sleeping disturbance were not synonymous with the patient’s clinical presentation. Moreover, diagnosis of CS cannot be made based on symptoms alone; but with the use of laboratory tests that measures the amount of cortisol in the patient saliva or urine and the clinical presentation according to PS (2015).

Premature Ovarian Failure (POF): According to American Society for Reproductive Medicine (ASRM, 2015), POF is cessation of ovarian functioning before age 40 due to autoimmune disorder affecting the thyroid and adrenal glands; family history of POF; and medical treatments, such as chemotherapy and radiation therapy. Symptoms of POF according to ASRM (2015) are similar with menopause, such as irregular menstrual periods, hot flashes, night sweats, irritability, vaginal dryness, and trouble sleeping. Premature ovarian failure is ruled out as the primary diagnosis because the symptoms associate with the condition are not synonymous with most of the symptoms presented by the patient.

PLAN:

Laboratory /Diagnostic Tests and Results:

The initial laboratory test that was completed was urine human chorionic gonadotropin level test to rule out pregnancy: Result- negative. Other laboratory/diagnostic tests include:

Blood tests like testosterone/androgen test: high/abnormal confirming high male sex hormones and the physical presentations; Prolactin test: level high/abnormal, + infertility; luteinizing /follicle-stimulating hormone blood level test are high and abnormal in this patient while the patient is not pregnant; cholesterol/triglycerides blood test: abnormal; TSH test: normal ruled out under/over active thyroid; hydroxyprogesterone: normal ruled out adrenal problem. Glucose tolerance/insulin levels: + insulin resistance.

Vaginal ultrasound (sonogram): + multiple cysts in the ovaries; thicker endometrium lining.

Treatment / Management Plan and Follow up Care

Polycystic ovarian syndrome is selected as the primary diagnosis after physical, laboratory, and diagnostic tests ruled out other possible differential diagnosis, and treatment/management plan for the condition will depend on the patient‘s needs or goals because there is no cure for the condition according to WH (2015). Treatment/management therapy typically focus on either fertility improvement or treating the symptoms of hyperandrogenism (hirsutism) explained by WH (2015); however, long term measures should be taken to restore regular menses and prevent endometrial hyperplasia. The patient desire is to become pregnant. Therefore, the first line of treatment, and the safest measure to restore ovulation is weight loss since patient is obese. Patient will be placed on calorie restricted diets, such as limiting carbohydrates and fats; eat more proteins, fruits/vegetables, and regular exercise (Tharpe, Farley & Jordan, 2013).

Medications:

Patient was advised to continue Motrin 200-400 mg orally every 6 to 8 hours as needed for pain.

Metformin 500 mg orally three time a day will be added with the aim of lowering growth of abnormal hair; help return of ovulation; lower body mass, enhance insulin resistance, and improve cholesterol levels (Tharpe et al., 2013).

Clomid 50 mg orally for 5 days is prescribed to treat the patient’s ovulatory dysfunction; the aim is to stimulate ovulation and treat infertility. Clomid therapy may be increased to100mg orally for 5 days if the initial therapy did not result in pregnancy when patient follow up in 6 months for reassessment (Tharpe et al., 2013).

Patient will be advised to follow up every 3 to 6 months for reassessment of the treatment and management therapy, such as insulin resistance reassessment, weight management, and reevaluation of clomid and metformin treatment/management therapy to determine the effectiveness of the therapy. Then, make therapy adjustments if needed accordingly (Tharpe et al., 2013).

Alternative Therapy

According to American Botanical Council (ABC, 2013), Chaste tree berry, licorice, and traditional Chinese medicine herb dong quai (Angelica sinensis) help to balance hormones in a patient with PCOS, they work well in restoring normal menstrual periods. Based on the confirmed effectiveness of chaste tree berry, licorice, and dong quai (angelica sinensis), they can be used as an alternative therapy to treat the patient PCOS. Furthermore, other herbs that can help with the patient’s menstrual and hormonal balance according to ABC (2013) are ginger, red raspberry, red clover, rosemary, soy, flax seed, partridge berry, and feverfew. In addition, legumes, chromium, cinnamon, tea (camellia sinensis), and/or coffee due to caffeine’s ability to improve insulin sensitivity; have been found to improve insulin resistance and would be recommended to the patient alternatively according to ABC (2013). Moreover, herbs like ginseng, licorice, ashwagandha, rhodiola, schisandra, and rhaponticum can be recommended for stress management explained by ABC (2013).

Nonpharmacological Treatment

Patient was advised to continue using heating pad as needed for pain. Sirmans and Pate (2014) described the nonpharmacological treatment of PCOS to include acupuncture, massage, homeopathy, reflexology, herbalism as aforementioned. According to Sirmans and Pate (2014), acupuncture is the most common used nonpharmacological treatment because women with PCOS use acupuncture to regulate and manage their periods. Women with PCOs also use acupuncture to help in weight reduction, headache reduction, and improvement in moods/outlook. Moreover diet and exercise will help in weight reduction, improve sensitivity to insulin and improve ovulation abnormalities associated with PCOS according to Sirmans and Pate (2014).

Health Promotion

Patient will be provided with age-appropriate educational materials on PICO causes, risk factors, diagnosis, and management therapy. Patient will also be reminded about the benefits of healthy lifestyle changes; nutrition & exercise; positive ways to cope with stress. Patient will be advised to incorporate regular exercise as part of her daily routine by exercising for a minimum of 20 to 30 minutes a day 4 to 5 times a week as well as eating fruits and vegetables; cut down on high fat/high cholesterol diet as well as include legumes in the patient’s diet (Tharpe et al., 2013). On-going support will also be made available for the patient. At every follow-up visit, patient’s concerns will be listened to and addressed. Clarification will be made about PCOS myths, ovarian cysts, infertility, and excess hair. Patient will be educated that there is no magic bullet about treating/managing the condition rather there are many ways to manage the presenting symptoms as well as lowering the risk for diabetes (Tharpe et al., 2013). Patient will be educated on the risk for other health problems associated with PCOS, such as risk of diabetes, risk of heart attack, greater risk of hypertension, high risk of having high cholesterol, and risk of developing sleep apnea. Also, patient will be educated about the risk of developing anxiety and depression due to the condition, but emphasis will be made on the importance of reaching out for help for mental health problem (Tharpe et al., 2013). Resources will be provided to the patient for help with weight loss and maintaining a healthy lifestyle. At this point, no referral was made because there was no identifiable need for referral.

Reflection Note Comment by Erica Gifford: Thorough reflection

I learned a lot from the experience. I learned that PCOS could be the primary cause of most infertility, and the cause is usually women sex hormonal imbalance. I equally learned that the increase in male hormone androgens could result in most of the physical changes associated with the condition. I also learned that maintaining a healthy weight is very crucial in managing the condition. I am thrilled to learn about alternative and nonpharmacological herbs that can help control insulin resistance in the body because the knowledge is personal to me and my family members.

I would not have done anything differently because I believed that I did an exhaustive patient assessment in collaboration with my preceptor based on the patient’s clinical presentation, and I followed the appropriate clinical guideline in collaboration with my preceptor to arrive at an appropriate primary/differential diagnosis, and management plan for the patient based on the patient wish to become pregnant. I selected the treatment plan as deemed appropriate and in consideration of the patient’s desires to have a baby.

I would have loved to gather additional data about the patient’s maternal grandmother or grate grandmother’s health history to determine if there is anybody in the patient’s family history that have PCOS. The information could explain the reason why the patient have the condition because PCOS is known to run in the family. But, the patient denied that her mother or siblings have the condition. Although, the patient informed the author and the author’s preceptor that she had limited knowledge of her maternal history because her mother was adopted. I would not have done additional elements of exam because the physical exam, laboratory, and diagnostic tests were very exhaustive based on the required clinical practice guidelines for the diagnosis of the condition.

I totally agreed with my preceptor’s clinical judgement and decisions based on the evidence, patient clinical presentation, physical examination, laboratory, and diagnostic tests. Also based on the evidence-based practice and clinical practice guidelines for PCOS.

References

American Botanical Council. (2013). Treating PCOS Naturally. HerbalEGram, 10(3), 1-4.

American Society for Reproductive Medicine. (2015). What is premature ovarian insufficiency

known as premature ovarian failure? Retrieved from http://www.socrei.org/uploadedFiles /ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/POF-final_1-5-12.pdf

Pituitary Society. (2015). Cushing’s syndrome & disease diagnosis. Retrieved from

https://pituitarysociety.org/patient-education/pituitary-disorders/cushings/diagnosis-of-cushings-disease-and-cushings-syndrome

Sirmans, S. M., & Pate, K. A. (2014). Epidemiology, diagnosis, and management of polycystic

Ovary syndrome. Clinical Epidemiology, 6, 1-13. doi: 10.2147/CLEP.S37559

Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for

midwifery & women’s health (4th ed.). Burlington, MA: Jones & Bartlett

Publishers

Women’s Health. (2014). Polycystic ovary syndrome fact sheet. Retrieved from

http://womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.html#a

SOAP note rubric

Subjective (15 points)

· CC

1

1

· Pertinent positives (OLDCARTS)

5

5

· Pertinent negatives (from ROS)

5

5

· Pertinent PMH, SH, and FH

3

3

· Medications and drug/food allergies are not included

1

1

Objective (15 points)

· VS including BMI, / FHT if indicated

2

2

· Heart and lungs and thyroid

1

1

· Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included.

-5

5

· Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted.

-5

45

· Diagnostic test results

2

2

Assessment – 10 points for each priority diagnosis (total 30 points) 30 30

Plan (15 points)

· Medications discontinued ("d/c lisinopril 10 mg daily”)

1

1

· Medications started (“start Avapro 150 mg daily”)

2

2

· Alternative therapies if appropriate (1 point)

1

1

· Health Promotion strategies – patient/family education

3

3

· Disease Prevention strategies with timeframe if appropriate

3

3

· Diagnostic tests ordered with timeframe (now, in 2 weeks, prior to f/u visit in 3 months)

3

3

· Referrals or consultations if appropriate

1

1

· Follow-up interval

1

1

Reflection notes (25 points)

· What did you learn from this experience? Any ah-ha’s? (5 points)

5

5

· What would you do differently?

5

5

· What additional data would you have gathered?

5

5

· What additional elements of the exam would you have done?

5

5

· Do you agree with your preceptor based on the evidence?

5

5

Total points

100

99100

Excellent SOAP note