Soap Note Women Health Assignment Discussion
Soap Note Women Health Assignment Discussion
Based on your assigned case study, post a Focused SOAP NOTE with the following:
Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.
Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning Soap Note Women Health Assignment Discussion
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Differential diagnosis
The case study presented with dysfunctional bleeding of client Gretchen Abernathy indicates excessive blood loss, which indulges the client into acquiring anemia. Dysfunctional Uterine Bleeding is the primary diagnosis. Dysfunctional uterine bleeding cause heavy menstrual bleeding, which is prolonged or heavy cyclic menstruation. Menses persisting longer than seven days or exceeding 80ml of blood loss indicate values. The patterns of menstrual flow, as explained by patient Gretchen Abernathy refer to intermenstrual bleeding or metrorrhagia Soap Note Women Health Assignment Discussion.
Dysfunctional intrauterine bleeding upholds to be the differential diagnosis. It is characterized by irregular bleeding. Women with anovulation due to amenorrhea for weeks to months followed by irregular, prolonged, and heavy bleeding causes intermenstrual bleeding (Wouk & Helton, 2019). The absence of progesterone production by the ovum causes the endometrium to respond to solid stimulation with proliferation. Low levels of estrogen stimulation contribute to irregular and prolonged bleeding, while long levels lead to episodes of amenorrhea followed by acute heavy bleeding.
Endometrial polyp. Endometrial poly is defined as fleshy intrauterine growth composed of fibrous stroma, endometrial glands, and the surfaces of the epithelium. Estrogen and progesterone are contributing causes in the development of bleeding, and higher receptor levels are noted within polyps compared with adjacent normal endometrium. Estrogen and progesterone hormones elongate endometrial glands and spiral arteries leading to polypoid appearance (Berek, 2017)Soap Note Women Health Assignment Discussion. Women experiencing polyps may have no complaints but more frequently exhibit heavy cyclic, or intermenstrual bleeding is a common symptom. Bleeding, however, arise from the spiral arteries from the break of the surface epithelium due to inflammation.
Polycystic ovarian syndrome is the most common endocrine disorder in reproductive-aged women. Women having polycystic ovarian experiences symptoms such as menstrual irregularities, infertility, and manifestations of androgen excess or endocrine dysfunctions. Menstrual dysfunction thus may range from amenorrhea to oligomenorrhea to menometrorrhagia. Menometrorrhagia refers to prolonged or excessive uterine bleeding. However, in distinction with amenorrhea, women with the polycystic ovarian syndrome may exhibit heavy and unpredictable bleeding. Weight gain, however, happens more in patients with polycystic ovarian syndrome. The patient reports menstrual bleeding has been getting worse since stopping oral contraceptive pills. OCPs are the first-line treatment of menstrual irregularities.
What I believe is most important diagnosis
An essential diagnosis the patient presents with is dysfunctional uterine bleeding. It is termed unusual bleeding without a specific etiologic factor. Often might be due to anovulation. When ovulation does not occur, no progesterone is produced, thus causing the proliferation of the endometrium to persist. Proliferation may extend to the tissue level causing a chronic proliferation leading to dilated and unstable venous capillaries. Anovulation and abnormal uterine bleeding also make criteria that are present in polycystic ovarian syndrome. Bleeding associated with anovulation results from an alteration in endometrial vascular structures, prostaglandin concentration, and increased responsiveness to vasodilating prostaglandins Soap Note Women Health Assignment Discussion.
Diagnostic tests
The diagnostic tests and treatment options that I recommend for the patient presented above with dysfunctional intrauterine bleeding are transvaginal ultrasound and complete blood counts.
Transvaginal ultrasound
Transvaginal ultrasound is significant in ruling out endometrial polyps and the etiologic cause of heavy menstrual bleeding. Transvaginal ultrasound is the primary diagnostic tool with color Doppler. Transvaginal ultrasound can be improved by using color or power Doppler (Motta et al., 2018). The endometrium contains one artery supplying the tissues, while the inner myometrium is well enriched with blood vessels. Transvaginal ultrasound may show a nonspecific endometrial thickening.
Complete blood counts
Taking blood for complete blood counts is a necessary test to rule out the cells that circulate in the blood, for instance, red blood cells, platelets, and white blood cells. Complete blood counts account for detecting various medical conditions, for example, anemia.
Treatment
Treating the underlying cause of dysfunctional uterine bleeding for instance anovulation is vital in controlling bleeding. Administering cyclic monthly progesterone while monitoring observation will regulate menses. Suitable treatments of dysfunctional intrauterine bleeding, which are given for ten days a month, include medroxyprogesterone acetate 5mg or 10mg, norethindrone acetate, and micronized progesterone 300mg (Hernández et al., 2020)Soap Note Women Health Assignment Discussion. Gonadotropin-releasing hormone agonists also prove a better treatment.
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References
Berek, Jonathan S. (2017) Berek & Novak’s Gynecology – 14th edition
Hernández-Marín, I., Villegas-Rodríguez, C. M., & Celis-González, C. (2020). Hormonals contraceptives in dysfunctional uterine bleeding patients. Ginecología y Obstetricia de México, 88(S1), 163-177.
Hoffman, B.L. et.al. (2016) Williams Gynecology – 3rd Edition
Motta, T., Laganà, A. S., & Vitale, S. G. (2018). Dysfunctional Uterine Bleeding. In Good Practice in Pediatric and Adolescent Gynecology (pp. 99-115). Springer, Cham.
Wouk, N., & Helton, M. (2019). Abnormal uterine bleeding in premenopausal women. American family physician, 99(7), 435-443 Soap Note Women Health Assignment Discussion