PLEASE RESPOND TO THE FOLLOWING POSTS WITH 2 PARAGRAPHS EACH AND 1 REFERENCE FOR EACH

 

PLEASE RESPOND TO THE FOLLOWING POSTS WITH 2 PARAGRAPHS EACH AND 1 REFERENCE FOR EACH

POST 1

Scernaio- 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.

Subjective:

Chief Complaint (CC): Barbara, a 48-year-old female, presents with complaints of irregular menstrual cycles, hot flashes, vaginal dryness, and decreased libido.

History of Present Illness (HPI): Barbara reports that her menstrual cycle has become irregular recently. She experiences hot flashes and vaginal dryness. Additionally, she notes a decline in her sexual desire. Barbara has been married for 20 years, is in a stable relationship, and has two daughters aged 16 and 18. She denies any significant medical history. Her pregnancy test, Pap smear, and STI panel are negative.

Medications: Barbara is not currently taking any medications.

Allergies: Barbara has no known allergies to medications.

Last Menstrual Period (LMP): 3/15/2024, has not had one since.

Gyn/OB History: G2P2 w/normal vaginal deliveries. She denies any history of gynecological issues.

Past Medical History (PMH): No PMHx. Patient denies hx of thyroid disease/problems.

Family History: No FMHx of breast or ovarian cancer.

• Social History: Barbara is married and has a stable family life. She does not smoke, use recreational drugs, or consume alcohol excessively. She works as a teacher and leads an active lifestyle.
• When gathering history of present illness (HPI) for Barbara, it’s important to ask about: Severity and frequency of hot flashes and vaginal dryness. Onset and duration of irregular menstrual cycles. Changes in mood or sleep patterns. Impact of symptoms on daily activities and quality of life. Any history of hormone-related conditions or treatments.
• Relevant medical history questions to ask Barbara include: Past or current use of hormonal medications (e.g., birth control pills, hormone replacement therapy). Any chronic medical conditions such as diabetes, hypertension, or thyroid disorders. Surgical history, especially related to the reproductive system (e.g., hysterectomy). Allergies to medications or other substances.
• Social history questions to ask may include: Occupational stressors and physical activity level. Smoking history and alcohol consumption. Diet and nutrition habits, including calcium and vitamin D intake. Support system and coping mechanisms for managing menopausal symptoms.
• Family history questions should focus on: Family history of hormonal disorders or early menopause. Any history of reproductive cancers (breast, ovarian, uterine). Genetic predispositions to conditions impacting hormonal balance.
• ROS:
• General: Denies weight loss or fatigue reported.
• Cardiovascular: Denies chest pain or palpitations.
• Respiratory: Denies cough or shortness of breath.
• Gastrointestinal: Denies abdominal pain or changes in bowel habits.
• Genitourinary/Gyn: Reports irregular menstrual cycles, denies abnormal bleeding or discharge, denies hx of abnormal paps.
• Breast: Denies and lumps or masses. No breast pain or tenderness reported. Denies nipple discharge (except for normal lactation during pregnancy/postpartum). Denies of changes in breast size or shape. Denies skin changes over the breasts (e.g., redness, dimpling, puckering). Denies nipple inversion or retraction. Denies previous breast surgeries or implants. Denies breast trauma or injuries. Denies breast infections (e.g., mastitis). Reports family history of breast cancer in mother.
• Integumentary: Denies all – No history of thyroid disease. No history of skin lesions, rashes, or itching. No changes in moles or pigmented areas noted. No history of excessive bruising or bleeding. No history of skin infections or ulcers. No history of hair loss or changes in hair texture. No history of allergic reactions.

Objective:

General: Barbara appears well-nourished and in no acute distress.

• Vital Signs: BP: 122/72 mmHg, Heart rate: 70 bpm, Respiratory rate: 16 breaths per minute, Temperature: 97.1°F, BMI: 22.6 kg/m².
• Pelvic Exam: Inspection: No external genital abnormalities or lesions.
• Speculum Examination: Normal vaginal walls without discharge or lesions.
• Bimanual Examination: Uterus is normal in size, shape, and position. No adnexal masses palpable.
• Breast Exam: No palpable masses or abnormalities noted on inspection.
• Physical Assessment:
• General Appearance: Barbara appears healthy and well-groomed.

Vital Signs: Blood pressure: 122/72 mmHg, Heart rate: 70 bpm, Respiratory rate: 16 breaths per minute, Temperature: 97.1°F, BMI: 22.6 kg/m².

Head and Neck: No palpable lymphadenopathy, thyroid gland normal in size and texture.

Breast Examination: No visible abnormalities, no palpable masses or tenderness in the breasts.

• Cardiovascular: Regular rate and rhythm, no murmurs or abnormal sounds.
• Respiratory: Clear lung sounds bilaterally, no wheezing or crackles noted.
• Abdominal Examination: Non-tender, no masses or organomegaly appreciated.

Pelvic Examination: Inspection: No external genital abnormalities or lesions.

Speculum Examination: Normal vaginal walls without discharge or lesions.

Bimanual Examination: Uterus is normal in size, shape, and position. No adnexal masses palpable.

• Skin Examination: Palpated thyroid- WNL. No rashes, lesions, or discoloration noted on the skin.

A detailed focused physical assessment for Barbara may include:

Vital signs: Blood pressure, heart rate, temperature.

• Pelvic exam to assess vaginal dryness, uterine size, and signs of atrophy.
• Breast exam for any abnormalities or tenderness.
• Skin assessment for signs of hormonal changes (e.g., dryness, thinning).
• Neurological exam to evaluate for mood changes or cognitive effects.
• B. Tests to order and perform, with rationale:
• Hormone levels (estradiol, FSH, LH) to assess menopausal status and hormonal imbalances (Ferrari et al., 2020).
• Thyroid function tests (TSH, T3, T4) due to potential impact on menstrual cycles and overall well-being.
• Lipid profile to evaluate cardiovascular risk factors, especially if considering hormone replacement therapy (HRT) (Dallongeville et al., 2017).
• Presumptive Diagnosis:
• Perimenopause with Associated Symptoms
• ICD-10 Code: N95.1 (Perimenopausal bleeding and menopausal symptoms)
• The presumptive diagnosis of Perimenopause with Associated Symptoms (ICD-10 Code: N95.1) is based on several key factors and clinical reasoning:

Age and Reproductive Stage: Barbara is a 48-year-old female, which is within the typical age range for perimenopause, the transitional phase leading to menopause. Perimenopause often starts in the mid-40s and can last for several years before menopause is reached.

Symptoms Consistent with Perimenopause: Barbara presents with classic symptoms associated with perimenopause, including irregular menstrual cycles, hot flashes, vaginal dryness, and decreased libido. These symptoms are commonly reported by women during the perimenopausal phase due to hormonal fluctuations (ACOG, 2018).

Exclusion of Other Causes: Barbara’s negative pregnancy test, normal Pap smear, and negative STI panel help rule out other potential causes of her symptoms, such as pregnancy-related changes, gynecological abnormalities, or infections.

Clinical Guidelines and Diagnostic Criteria: The ICD-10 code N95.1 specifically denotes perimenopausal bleeding and menopausal symptoms. Using this code aligns with established clinical guidelines and diagnostic criteria for perimenopause, as defined by organizations like the American College of Obstetricians and Gynecologists (ACOG) and the North American Menopause Society (NAMS).

Patient History and Presentation: Barbara’s history of stable relationships, age-appropriate symptoms, and absence of significant medical issues contribute to the likelihood of perimenopause as the presumptive diagnosis.

Differential Diagnoses:

Menopause

ICD-10 Code: N95.0 (Menopausal and female climacteric states)

Reasoning: Barbara’s age, symptoms of irregular menstrual cycles, hot flashes, vaginal dryness, and decreased libido are indicative of perimenopause. However, considering her age and symptomatology, menopause itself is also a possible diagnosis (NHS, 2022).

Hormonal Imbalances

ICD-10 Code: E28.9 (Other ovarian dysfunction)

Reasoning: Hormonal imbalances unrelated to menopause can also cause irregular menstrual cycles, hot flashes, and changes in libido. Further testing of hormone levels is necessary to rule out this possibility.

• Thyroid Dysfunction

ICD-10 Code: E03.9 (Hypothyroidism, unspecified)

• Reasoning: Thyroid dysfunction, particularly hypothyroidism, can present with symptoms similar to perimenopause such as fatigue, weight changes, and mood disturbances. Thyroid function tests should be included in the diagnostic workup (Frank-Raue, K., & Raue, F, 2023).
• Stress-Related Symptoms
• ICD-10 Code: F43.9 (Reaction to severe stress, unspecified)

Reasoning: Stress can manifest with a variety of physical and emotional symptoms, including irregular menstrual cycles, changes in libido, and mood swings. Given Barbara’s stable family life and occupation as a teacher, stress-related factors should be considered and addressed during evaluation (Mayo Clinic, 2022).

• Assessment/Diagnosis:

A. Presumptive diagnosis and expected results: Presumptive diagnosis: Perimenopausal transition with hormonal imbalance, based on symptoms and hormonal profile.

• Expected results: Elevated FSH and LH levels, decreased estradiol levels, and possibly thyroid dysfunction markers if present.

B. Additional diagnosis or differential: Differential diagnosis may include thyroid disorders, polycystic ovary syndrome (PCOS), or other endocrine abnormalities impacting menstrual cycles.

• Plan:

Hormone therapy:

• Prescribe hormone replacement therapy (HRT) based on hormone levels and menopausal symptoms to alleviate hot flashes, vaginal dryness, and improve libido (Smith & Jones, 2020). Educate Barbara on the benefits, risks, and alternatives of HRT, including potential side effects and long-term considerations.

Lifestyle modifications:

Encourage regular exercise, a balanced diet rich in calcium and vitamin D, adequate sleep, stress management techniques, and smoking cessation to promote overall well-being during menopausal transition. The use of lubrication for comfort during sexual relations (Scavello, 2019).

Psychosexual counseling:

Possibly refer Barbara and her partner to psychosexual counseling to address intimacy issues and enhance communication regarding changes in sexual desire and function (Rani S., 2009).

1. Follow-up:

Schedule follow-up appointments to monitor response to HRT, adjust dosage if necessary, and address any concerns or new symptoms.

• Support resources:
• Provide educational materials, support groups, and online resources for menopausal women to empower Barbara in managing her symptoms and making informed decisions about her health.

1. A. Management plan for Barbara: Prescribe hormone replacement therapy (HRT) based on hormone levels and symptom severity (Stuenkel et al., 2021).  Consider non-hormonal options for symptom management if HRT is contraindicated or not preferred.

B. Treatment guidelines and side effects: Explain the benefits of HRT in alleviating menopausal symptoms but also discuss potential risks such as increased risk of breast cancer and cardiovascular events (Manson et al., 2019). Educate about alternative therapies like herbal supplements or lifestyle modifications for symptom relief.

• C. Patient education: Educate Barbara about the importance of calcium and vitamin D intake for bone health during menopause (ACOG, 2020). Discuss the role of regular exercise, stress management, and adequate sleep in managing menopausal symptoms.
• D. Follow-up plan of care: Schedule follow-up visits at intervals to monitor response to treatment, adjust dosage if needed, and address any new concerns or side effects. Provide resources for ongoing support and education on menopause management.

1. POST 2 

SOAP NOTE

• Subjective
• CC: “I often urinate accidentally when I cough, sneeze, or laugh and it is becoming worse. I also feel something at the entrance of my vagina.”

1. HPI: A 63-year-old patient in office today with complaint of worsening accidental urination when sneezing, laughing, or coughing. Patient states intermittent urination has happened since the birth of her last 3 children (last birth was 1992) but has become worse during the past year. She reports having to wear a sanitary pad and is concerned about odor at times. She states she must change her sanitary pad every 4-6 hours due to increased leakage. Patient also reports feeling “something at entrance” of vagina. She states this began a few months ago but reports there is no pain present. She states that she does not want to undergo any type of surgery for treatment and would like to explore other treatment options. No other complaints or concerns at this time.

Medications: N/A

• Allergies: No known allergies
• LMP: 4/1/2012

Gyn/OB history: G7P7. NSVD x7. No significant OB history. Last pap 2023. No abnormal pap history. No STI history, Menarche 12 years old.

PMH: None

Chronic Illness/ Major trauma: No history of chronic illness/trauma.

Family Hx: Mother- DM II, depression / Father: DM II, COPD, Lung CA

Social Hx: Denies alcohol consumption, and illicit drug use. Currently not sexually active. Sexual partner history: 2. Last sexual encounter 9 year ago. Pt has been working as librarian for past 30 years and reports having to move heavy boxes at times which causes accidental urination. She states that she has a good support system of family and friends around her.

ROS

General: Denies fever, malaise, chills.

Eyes: Denies vision disturbances, loss, changes.

ENT: Denies hearing loss, changes in hearing. Denies nasal drainage/congestion. Denies sore throat, difficulty swallowing.

Cardiovascular: Denies chest pain, tightness. Denies palpitations.

Respiratory: Denies cough, phlegm production. Denies difficulty breathing.

GI: Denies n/v. Denies diarrhea/constipation. Denies abdominal tenderness.

Breast: Denies breast pain, lumps, changes in appearance/size. Denies family hx of breast CA.

Endocrine: Denies frequent thirst/hunger. Denies cold/hot intolerance.

GU/GYN: Reports worsening urine leakage when she laughs, sneezes, or coughs. Also reports feeling “something at entrance” of vagina.  Denies painful urination. Denies frequent urge to urinate. Denies difficult urination. Denies flank pain. Denies abnormal discharge. Denies suprapubic pain.

Psych: Denies anxiety and depression.

Neuro:  Denies headache. Denies seizures and loss of consciousness.

Objective Data

VS

BP: 120/80 HR: 80 RR 16 Temp: 97.1 F Spo2 99% on RA

Ht: 5’3” Wt: 140 lbs. BMI: 24

Const./General: Alert. Well-groomed. Appears stated age. No acute distress.

HEENT: Atraumatic, normocephalic. PERRLA. White sclerae. TMs clear, pearly gray. Patent nares, no drainage noted. Pink mucosa with no visible lesions. Good dentition. Tongue and uvula both midline.

Neck: Supple. No lymphadenopathy

Respiratory: CTAB. Unlabored breathing. No adventitious lung sounds noted.

Cardiovascular: s1, s2 without murmurs or gallops.

GI: Normoactive bowel sounds. No hepatosplenomegaly on exam. No abdominal tenderness or distension noted,

Gyn: Visible bulge noted on anterior vaginal wall. Soft, fleshy mass palpated is consistent with cystocele and is approximately 1 cm in diameter at 12 o’clock of vaginal entrance. Exacerbation of bulge sensation with straining maneuvers. Pink, moist vaginal walls noted without lesions. Cervix appears pink with changes consistent with multiparty. No discharge or bleeding noted. No signs of irritation or inflammation upon inspection. No adnexal tenderness or cervical motion tenderness noted.

Rectal: Normal rectal sphincter tone without any palpable abnormalities or masses. No evidence of bleeding. No tenderness during examination. No hemorrhoids noted.

Integumentary: Skin warm, dry and intact. No lesions, bruises or rashes noted.

Extremities: No edema. Pulses +2 radial/pedal.

Psych: A&O x3. Appropriate behavior/responses throughout interview and exam.

———-

POC testing: U/A

Assessment/ Diagnosis

Presumptive diagnosis:

Anterior vaginal wall prolapse (Stage 1)

Differential diagnoses:

Posterior vaginal wall prolapse

Diagnoses rationale: I selected anterior vaginal wall prolapse as my working diagnosis because of the location of the prolapse (12 o’clock) and because of the patient’s symptoms. Urinary symptoms such as stress incontinence are typically associated with anterior vaginal wall prolapse (Rogers & Fashkoun, 2024). I believe her prolapse should be stage 1 as far as grading because her prolapse is not more than 1 cm (Rogers & Fashkoun, 2024). In addition, more advanced stages are typically not associated with urinary incontinence due to urethral kinking and resistance which results in obstruction (Alexander et al., 2024). Posterior vaginal wall prolapse is less likely as the patient does not present with any constipation or anal obstruction and because of prolapse location.

Plan

Diagnostic tests

Postvoid residual urine volume measurement

Simple cystometry (Alexander et al., 2024).

Lab Tests

U/A + C/S

Medication

None at this time

Referrals

PT for pelvic floor muscle therapy

Gynecology referral for further management and possible vaginal pessary

Education

Explanation of prolapse and causes of prolapse (most likely multiple pregnancy/vaginal deliveries in the case of this patient).

Conservative management is the first line option for management and includes vaginal pessary and pelvic floor muscle therapy. If unsuccessful, surgery may be the next option. Recurrence of prolapse is a possibility and prognosis is dependent on symptom severity (Rogers & Fashokun, 2024).

Physical therapy / pelvic floor muscle therapy will not reverse anatomic changes that have occurred because of the prolapse, however it will help with symptoms (urinary frequency and incontinence) (Alexander et al., 2024).

Pessary therapy may also help with symptoms. Fitting of the pessary is done through trial and error. It is important to maintain future appointments to ensure there is no erosion or irritation caused by the pessary (Alexander et al., 2024).

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