Gynecologic Health Essay
Episodic/Focused SOAP Note
E.G 38-year-old female
CC (chief complaint): “She states that she is not interested in having more children but her new partner has never fathered a child.”
HPI: E.G is a 38-year-old female presenting to the clinic to discuss contraceptive options. She reports that she is not interested in having more children but her new partner has never fathered a child. She reports a positive history of exercise-induced asthma, migraines, and Inflammatory Bowel Syndrome. She reports no known drug or food allergies and is currently on vitamin C. Her history of hospitalizations was only in childbirth.
Current Medications: She reports to be currently on Vitamin C.
It is important to ascertain if she uses any herbal products and use of over counter drugs. Some drugs that are liver enzyme inducers like the anti-TB drug Rifampicin reduce the bioavailability of hormonal contraception hence lowering their efficacy (Zhang et al., 2018). For this reason, this information has to be known for the prescription of efficacious contraception. Knowledge of the history and duration of corticosteroid use is critical to rule out DMPA use as chronic steroid therapy is associated with reduced bone density.
Allergies: She reports having no known drug or food allergies.
PMHx: She reports a positive past medical history of exercise-induced asthma, migraines, and Inflammatory Bowel Syndrome. She reports having only been hospitalized during the periods of childbirth.
It would be important to know if there is any history of the treatment of any sexually transmitted infection. It is also essential to ask about the date of the last tetanus vaccination for this client.
Social and Substance History: EG reports that she uses marijuana daily. She denies any history of alcohol or tobacco use. She reports having a new partner. Other useful questions in the social and substance history would be the duration of her use of marijuana, her current relationship with the rest of her family, what are her hobbies, what she does for a living, and who are her support system.
Family History: She reports that both her mother and father are alive. She reports that her mother has osteopenia and fibromyalgia. She reports that her dad has basal cell skin cancer. She reports that her older sister has endometriosis. Her sister also has venous thrombi during her second pregnancy. She reports that her maternal grandmother has dementia. She also reports that her maternal grandfather has COPD. She reports that both paternal grandparents died due to an automobile accident.
It is important to know whether there is any history of breast cancer as it will help inform the appropriate contraception to be used. In case of a positive family history of BRCA 1 mutations in first-degree relatives, combined oral contraceptives are ruled out as they increase the risk for breast cancer. It is associated with an increased risk of 20% for breast cancer (White, 2018). Additionally, a family history of osteoporosis or defective bone mineralization is crucial in considering depot medroxyprogesterone acetate (DMPA) for contraception as it interferes with bone mineralization.
Surgical History: She reports having had a tonsillectomy in childhood.
Mental History: There is no reported history of mental illness or treatment of a mental illness for the patient.
Violence History: There is no reported history of domestic violence or partner violence.
Reproductive History: E.G is para 5 gravida 5 with 6 living children.
Important aspects of her reproductive history that would be crucial are her menstrual history which includes the length of her cycle, when the last menstrual period occurred, the regularity of her menses, and the type of menstrual flow whether she has a heavy or light menstrual flow. It is also essential to establish any history of contraceptive use, the age of her last born child, whether she is breastfeeding or not, and whether she would wish to have a child with her new partner.
Review Of Systems:
GENERAL: No loss of weight, no fever, no general body malaise, and no chills.
HEENT: Eyes: No loss of vision, no blurring of vision, no exophthalmos, no tearing no photophobia, and no double vision, or scleral jaundice. Ears, Nose, Throat: No loss of hearing, no ear discharge, no sneezing, no nasal congestion, no throat soreness or pain.
SKIN: No skin rash or itching. No skin striae or any abnormal skin growths.
CARDIOVASCULAR: No chest or shoulder pain, no chest pressure. No palpitations or limb edema.
RESPIRATORY: No dyspnea, no cough.
GASTROINTESTINAL: No loss of appetite, no abdominal pain, no nausea, vomiting, loose stools, or constipation. No blood in the stool.
NEUROLOGICAL: She reports headache preceding her menses, no dizziness, no syncopal attacks, no limb weakness, no paralysis no numbness, or tingling in the extremities. No sphincter incontinence. No tremors or gait changes.
MUSCULOSKELETAL: No back pain, no joint swelling, no joint pain, no restriction in the joints’ range of motion.
HEMATOLOGIC: No pallor, no petechial hemorrhages, no easy bruising.
LYMPHATICS: No lymphadenopathy. No history of splenectomy.
PSYCHIATRIC: No history of psychiatric illness, no history of anxiety or depression.
ENDOCRINOLOGIC: No reported change in skin pigmentation, no palpitations, no cold or heat intolerance, no polyuria, polydipsia, or polyphagia.
GENITOURINARY/REPRODUCTIVE: No change in urinary frequency or urgency. No burning sensation on urination. No lesions or warts in the genital area. The breasts have fibrocystic changes bilaterally, no breast masses, and no dimpling or breast discharge. No vaginal discharge.
It would be important to ascertain if the client is currently pregnant or breastfeeding by seeking the last menstrual period. This would help in deciding on the ideal contraceptive.
ALLERGIES: No reported history of allergies to drugs or food.
General Exam: A middle-aged woman in fair general condition. She looks her age. She is conscious and oriented to time, place, and person. She is not in any obvious pain or respiratory distress.
Height 5’ 7”, Weight 148 lbs. BMI 23.1. Blood Pressure 118/72 mmHg. Pulse rate 68
HEENT: The head is normocephalic. There are no anatomical abnormalities in the Head, ears, eyes, nose, or throat. The neck is supple and flexible. There is no pain in neck movement. There is no neck adenopathy.
The chest is moving symmetrically in breathing. No chest deformities. It is resonant to percussion bilaterally. Equal air entry bilaterally and no added sounds.
The Breasts are soft, they have fibrocystic changes bilaterally, without masses, no dimpling or discharge
The Abdomen is moving with respiration. No abdominal masses. It is soft. Abdominal sounds are present. There is no tenderness.
There is no adnexal mass or tenderness.
The Cervix is firm, smooth, and parous. There is no cervical motion tenderness.
The Uterus is mid, mobile, and non-tender, measuring approximately 8 cm.
Breast Ultrasound: The patient is 38 years old and still in her reproductive age. Based on these facts, her mode of choice for breast imaging of breast masses is ultrasound (Lowry et al., 2020). Mammography may be done to characterize a suspicious lesion found during the ultrasound.
A transvaginal ultrasound would be important in assessing the cause of menstrual pain.
Gonococcal test: This will help rule out STIs. The patient is sexually active and based on her history she has changed partners. Offering this test before contraception I important.
Activated Protein C Test: This will help assess the presence of Leiden Factor V Mutation (Eppenberger et al., 2022). This is useful in deciding on an appropriate contraception method.
Menstrual Migraines: During the patient’s history taking and physical examination, she complained of migraines which had a temporal relationship with her menses and periods of stress. The association between her migraines and her periods could suggest that she was having menstrual migraines. She meets the diagnostic criteria for menstrual migraines which according to the International Headache Society is a diagnosis of migraine, timing, and frequency of migraine attacks (Vetvik & MacGregor, 2021). Her migraine attacks occur around the period of her menses.
Dysmenorrhea: The patient reported headaches during the earlier days of her periods. Dysmenorrhea is a major contributing factor to headaches as there is prostaglandin release and estrogen withdrawal during menstruation (Alsaleem, 2018).
Fibrocystic Breast Disease: During the physical examination, the patient was found to have fibrocystic changes bilaterally. Fibrocystic changes often manifest as breast nodules. Fibrocystic changes are commonly benign disorders of the breast that affect 90% of women in their lifetime (Chen et al., 2018). It is common in women aged 20-50 years (Chen et al., 2018). The most common form of fibrocystic changes is biphasic tumors which comprise phyllodes tumors and fibroadenomas. Others include papillomas and cysts. The absence of breast skin changes is important to tentatively rule out any breast malignancies.
The management of this patient entails pharmacological and non-pharmacological approaches to prevent pregnancy and improve overall health. The first approach in her management would be patient counseling and education on the most appropriate contraceptive method. This includes informing the patient on the appropriate contraception, mechanism of action, and side effects of the method. The patient’s mother has osteopenia. This is a first-degree relative to the patient. In this case, because of the family history of osteopenia, DMPA is less likely. The patient is already having menstrual pain. An Intrauterine Contraceptive Device (IUCD) is associated with severe menstrual pain (Hocaoğlu et al., 2021). Menstrual pain and increased menstrual bleeding are the commonest reasons for dropping out of the IUCD method. Her sister also lost her second pregnancy due to a thromboembolic disorder. With this family history, it is important to avoid combined oral contraceptives as they increase the risk for VTE, especially in patients with Leiden factor V mutation.
Based on the above observations, hormonal contraception offers more advantages to this patient despite the risks. This patient has a remarkable history of exercise-induced asthma. Hormonal contraceptives such as the COCs reduce the severity of asthma attacks (Nwaru et al., 2020). Hormonal contraception also reduces the occurrence of menstrual migraines as they ensure hormones are balanced throughout the menstrual cycle. This contraception may also reduce the number of menses which ultimately reduces the frequency of occurrence of menstrual migraines. Another plausible method is the barrier method of contraception which include male and female condoms. She also does not want any more children hence a good candidate for bilateral tubal ligation. However, with BTL, since her partner wants to have children, family counseling is paramount. These family planning methods would be suggested to the patient to make an informed choice. I would recommend combined oral contraceptives despite the pill burden.
The non-pharmacological management is patient education on the available contraception methods. It is also cardinal to address questions and misconceptions that she might harbor concerning different contraception methods. Counseling the patient and her partner is far-reaching in ensuring family cohesion even after contraception.
Contraception is often a challenging case. The chosen method must address the patient’s primary concern which is that she does not want to have any more children. At the same time, it has to address pertinent issues that have emerged in her history. These are issues of menstrual migraine and exercise-induced asthma. The lesson drawn from this case is the importance of paying attention to the patient’s needs and offering individualized care. Involving patients in care is also essential. I would not do anything differently. Patient education is a crucial part of management. Education on different contraception methods, adherence to the prescribed contraception method, safe sex practices, and cervical cancer screening is important.
Further Information Needed
Additional information will be needed to perfectly individualize an effective intervention to meet her needs. The information includes any history of contraception used before. If there is, what method has she used before and why did she stop? It is important to know which contraception method she has considered during the current visit. It is also important to know how many sexual partners she has had over the past year to understand her sexual behavior and correctly stratify her sexual risk. In the reproductive history, it is important to know the duration of her cycle, regularity, and the nature of her periods; whether heavy or light. It is also essential to know when she last had a gynecological exam and what the results were. Finally, she has migraines. It is essential to know if they are preceded by an aura or not.
Alsaleem, M. A. (2018). Dysmenorrhea, associated symptoms, and management among students at King Khalid University, Saudi Arabia: An exploratory study. Journal of Family Medicine and Primary Care, 7(4), 769–774. https://doi.org/10.4103/jfmpc.jfmpc_113_18
Chen, Y.-Y., Fang, W.-H., Wang, C.-C., Kao, T.-W., Chang, Y.-W., Yang, H.-F., Wu, C.-J., Sun, Y.-S., & Chen, W.-L. (2018). Examining the associations among fibrocystic breast change, total lean mass, and percent body fat. Scientific Reports, 8(1). https://doi.org/10.1038/s41598-018-27546-3
Eppenberger, D., Nilius, H., Anagnostelis, B., Huber, C. A., & Nagler, M. (2022). Current knowledge on factor V Leiden mutation as a risk factor for recurrent venous thromboembolism: A systematic review and meta-analysis. Frontiers in Cardiovascular Medicine, 9, 883986. https://doi.org/10.3389/fcvm.2022.883986
Hocaoglu, M., Gunay, T., Demircivi Bor, E., Nur, A. G., Turgut, A., & Karateke, A. (2021). Comparison of intrauterine device insertion-related pain and ease of procedure at different times during menstruation. Medeniyet Medical Journal, 36(3), 225–232. https://doi.org/10.5222/MMJ.2021.89633
Lowry, K. P., Coley, R. Y., Miglioretti, D. L., Kerlikowske, K., Henderson, L. M., Onega, T., Sprague, B. L., Lee, J. M., Herschorn, S., Tosteson, A. N. A., Rauscher, G., & Lee, C. I. (2020). Screening performance of digital breast tomosynthesis vs digital mammography in community practice by patient age, screening round, and breast density. JAMA Network Open, 3(7), e2011792. https://doi.org/10.1001/jamanetworkopen.2020.11792
Nwaru, B. I., Tibble, H., Shah, S. A., Pillinger, R., McLean, S., Ryan, D. P., Critchley, H., Price, D. B., Hawrylowicz, C. M., Simpson, C. R., Soyiri, I. N., Appiagyei, F., & Sheikh, A. (2021). Hormonal contraception and the risk of severe asthma exacerbation: 17-year population-based cohort study. Thorax, 76(2), 109–115. https://doi.org/10.1136/thoraxjnl-2020-215540
Vetvik, K. G., & MacGregor, E. A. (2021). Menstrual migraine: a distinct disorder needing greater recognition. Lancet Neurology, 20(4), 304–315. https://doi.org/10.1016/S1474-4422(20)30482-8
White, N. D. (2018). Hormonal contraception and breast cancer risk. American Journal of Lifestyle Medicine, 12(3), 224–226. https://doi.org/10.1177/1559827618754833
Zhang, N., Shon, J., Kim, M.-J., Yu, C., Zhang, L., Huang, S.-M., Lee, L., Tran, D., & Li, L. (2018). Role of CYP3A in oral contraceptives clearance. Clinical and Translational Science, 11(3), 251–260. https://doi.org/10.1111/cts.12499
Case Study Discussion
Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, diagnostic approaches, as well as the development of treatment plans.
For this Case Study Discussion, you will review a case study scenario to obtain information related to a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop treatment and management plans.
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
- By Day 1 of this week, you will be assigned to a specific case study scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your case study assignment from your Instructor.
- Review the Learning Resources for this week and pay close attention to the media program related to the basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources.
- Carefully review the clinical guideline resources specific to your assigned case study.
- Use the Focused SOAP Note Template found in the Learning Resources to support Discussion. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your SOAP note. This will help you develop your differential diagnosis and additional questions
BY DAY 3
Please POST your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations.
Read a selection of your colleagues’ responses.