CASE STUDY: OB- Chief Complaint: Prenatal Visit -

CASE STUDY & SOAP NOTES 2

CASE STUDY & SOAP NOTES 2

CASE STUDY & SOAP NOTES 2

Cue Study # 3 - ELOG #13590073

CC: "I nave been having irregular periods for the past 5 months since I have stopped taking my birth control pills."

HPI: M.A-P is a 30 y/o nulliparous African Canadian female that presents to the clinic today c/o in•egular periods for the paot 5 months after stopping her COC pills. Pt has been taking COC pills for 5 years but decided to stop. Denies trying for pregnancy at this time. Pt LMP 01/08 20. Denies ACHES. Admitted to taking a pregnancy vest the first and third month she missed her period- which was negative. Current means of contraceptives is barrier method of cond nms.

Admitted to using levonorgestrel pill ( Plan B) one time 2 months ago fo pregnancy prophylaxis y,hich resulted in ha having a period that month since stopping the CDC pills. While on COC pills and prior to its use admits to having regular menses. Menstrual cycle was regular q 28 days, lasting 4-6 days. Denies having any dyspareunia, vaginal discharge, bleeding or odour. Pt has had sexual partners in the past 2 years. Currently denies having dysuria. Denies any fatigue, malaise or fever. of left and right ovarian cysts, anxiety, high cholesterol and hemorrhokds. Last STI and PAP testinp was 2018 - negative. Denies any history of STI's or abnormal PAP's. Denies any N&V, fever. aches and chills. No weight change or change in eating pattern.FMHX; Mother- H TN hyperlipidemia, breast cancer. Father- high cholesterol and ETOT-I abuse. Sister- PCOS, fibroids and diabetes. Brother- healthy

Referral source: Patient

Source and Reliability: Patien& came into the clinic on her own today Patient seems like a reliable source.

Social history: Currently wolking in telecommunications. Denies smoking or use of other illicit drug use. Admits to ETOH 14 glass per week.

OB/GYN Histor«r :

N/lenstrual history: patient got her penod at the age of 13. Pt admits to having regular periods each month Mith the cycle being ever, 28 days lasting 4-6 days, but not in the 5 months ago.

· Contraception: Was taking COC pills for the past 5 years. Admits to using condoms as well.

· Cervical and Cytology: Last PAP and STI testing done in 2018. Pregnancy/obstetric history: No previous pregnancies Sexual history: L sexual partners in the last 2 years. GYN Problems/ Procedures:

· Last pap summer of 2018-negative as per the patient. c Ovarian cyst on the left and right side since (2012)

General Medical History:

· Medical history: hyperlipidemia (2018). Eczema (2012)

· Aledication: Alesse 28 PO once a day

Allergies: No medical or environmental allergies

· Immunizations: Up to date on immunizations as per the patient.

· Health Maintenance: Plans to take this year flu vaccine. Pt received Gardasil vaccine (unsure of the year).

· Family History Mother- HTN, Hyperlipidemia, breast ca. Father- high cholesterol and ETOH abuse. Sister, POOS, fibroids and diabetes. Brother- healthy. Surgeries/procedures hemorrhoid bands (2016) Review of Systems:

General: Denies any weight loss or admits to feeling fatigued. Denies any fever "r chills. Denies any change in appetite.

Skin: Admits to having acne around the cheek and chin for the Dast 1 year. Feels that wearing masks because of CD VID has ".orsened lt. Denies an rashes, moles, lesion or sores. Lenies pruritic or dry Dkin. Denies change of colour or ,exture to the skin, hair or nails.

Head, Eyes, Ears, Nose- Throat UENT):

Head- Denies headaches, no head injuries

Eyes, Denies erythema to the eyes. no change in vision. Denies straining or having visual issues.

Ears- Denies any ear pam, tinnitus or ear drainage.

Nose- no history of nose bleeds.

Throat- no sinus issues, frequent colds, nasal stuffiness or nose bleeds. Denies sore throat, voice hoarseness or dental disease.

Neck: Denies any lumps of the neck. Denies any pain wiLh swallowing. No issues with eating food.

Breast: Denies any breast nodules or masses. Denies any nipple retraction, skin dimpling, or any changes in moles or skin color and consistency. Denies that she performs self -breast examination.

Respiratory: Denies any recent cough, sputum, wheezing or SOB. changes in breathing. No documentation of her last cnest-x-ray at this clime.

Cardiovascular: Denies chesL pain or feeling SOB. No known heart disease or blood high pressure. No paroxysmal noctumal dyspnea. dyspnea, or orthopnea. No palpations or edema of the hanc:L and ankles.

Gastrointestinal: denies change in appetite, denies nausea or vomiting. denies change in bowel habits. Denies general flatus. No issues with swallowing, No jaundice, gallbladder, liver problems.

Genitourinary and Gynecology: Admits to having irregular periods for 5 months. No dysuria, dyspareunia or abnormal bleedmg/ spotting. No vagmal discharge, pruritus or odour. Demes pelvic pain.

Musculoskeletal: denies any joint pains, bone pain or issues with mobilization. No previous fractures .

Psychiatric: No history of depression, buf has hx of anxiety that managed with cognitive behavioural strategies. Denies and suicidal ideations or Dlans.

Neurological: Denies tremors or vcrtigo. Denies dizziness or headaches or migraines. No syncope episodes. Denies tremors or involuntary movements. Denies any history of radiation exposure to the head or neck.

Hematologic: No anemia or history of bruising. No history of nose bleeds or blood transfusion or previous transfusions or reactions. No family history of blood disorders. Endocrine: No history of thyroid trouble or heat or cold intolerance.

Physical Examination:

General: M.A-P is a 30 y/o female that presents to the clinic. Patient is well-groomed and dressed during the examination. No signs of distress or use of accessary muscles or pair during this examination. Patient is African Canadian female. No facial yimacing noted. BMI 28.7 signs: Temp- 36.2. Celsius (Tympanic) RR- 14 with no distress. HR is regular at 80 beatymin. Pulse oximetrv not available at the clime. B/P 1 12/55, Wt 183 lbs, Ht 5'" ft.

Neurological: Alert and orientatcd x 3. Speech is clear and with good tone. Steady gait during ambulation in and out of the examination room.

Skin: Scattered course hair noted around the chin and the umbilical area. Fine light hair noted on two areas of the neck. Darker pigmentation noted to the neck folds, armoits and inner thigh bilaterally. ho rashes to the abdomen or face. Not pale or diaphoretic. Patient is warm to touch, temperature taken, and It was 36.2 Celsius (tympanic). Nails beds are pink. cab refill <2seconds without clubbing or cyanosiu.

Cardiovascular: Pt is warm to touch, brachial pulses and femoral pulses palpable. Nonnal sl and s2 with no munnur rub or gallop, no heaves or thrills. PMI is non-displaced and located at 5 th intercostal space. Radial pulses 2+ equal bilaterally. Capillary refill less than 2 seconds. No peripheral edema to Iowa and upper extremities. No edema to the limbs. Dorsalis pedls pulse posterior tibial pulses and poplitea[ pulses palpable. Calves are non-tender and not swollen.

Head, Eyes, Ears, Nose, Throat (HEENT):

Head: is normocephalic and atraumatic, hair colour is black. Scalp has no lesions. Hair evenly distributed with average texture. No hair loss noted.

Eyes: conjunctiva pink and sclera are white. During fundus eye examination, red reflex noted, no A-V nicking or arteriolar narrowing. EOM intact.

Ears: Ears examined with otoscope, tymnanic membranes intact, pearly grey bilaterally and his ear canals have minimal cerumen. TM have cone of light at 7 0'clock for left ear and 5 ( 'clock for right ear.

Nose: Nasal mucosa is Pink, and septum is No polyps or sinus tenderness, rhinorrhea with clear discharge noted bilaterally.

Throat: tonsils are bilaterally oral mucosa is moist, no uxudate on the pharynx. Dentition good. tongue and uvula midline.

Neck: Neck is symmetrical in appearance. other lumps noted in the head, axillae, chest or abdomen. No goiter noted. No masses palpated on thyroid. Denies any difficulty or pain Wth swallowing

Lymph nodes: No lymphadenopathy noted. No regional lymphadenopathy to the axillary and supraclavicular and infraclavicular.

Breast:

Inspection: Breast appears symmetrical In size during the inspection no breast retractions, dimple or creases noted bilaterally. breast straw stretch marks noted. No Peau d 'orange Areola's are symmetrical, no nipple d/c noted. Large aerola dark brown in colour, Montgomery nipple glands noted on breast bilaterally.

Palpation: Skin warm to touch. No bilateral breast pain during supine palpation. No nipple discharge during palpation. No swelling, redness or edema noted. No lump m the breast bilaterally and no masses and in the tail of spence axil area. No lymphadenopathy of the infraclavicular and supracla-•icular noues.

Thorax and lungs. Inspection ofthnrax completed elliptical in shape. No retractions or use of accessorv muscles. No crepitus during palpation. Lung expansion bilateral. Tactile fremitus negative. During auscultationu no adventitious sounds noted.

Abdomen: Ilyperactive bowel sounds to all four quadrants. Abdomen soft and non-tender. No rebouding guarding noted during the exammatron. No hepatosplenomegaly noted

Pelvic Exam: Extemal genitalia- hair distribution of nonnal female pattem. No vulvar erythema or lesions. Vaginal mucosa pink, rugae present-no d/c noted . Cervix: pink, cervical os round and centered. no bleeding, DOIyps or cervical d/c. No tenderness to the Bartholin or skene glands. Bimanual: retroverted uterus, uterus mobile, soft and nontender. adnexal tenderness or masses. CMT negative

Rectal: no extemal hemorrhoids noted

Assessment: Secondary Amenorrhea -POOS

· There are multinle causes of secondary amenorrhea. Amenorrhea can be a transient, intermittent, or permanent condition. Comrnon of causes amenorrhea can include dysfunction of the hypothalamus, pituitary, ovaries, uterus, or vagina.

· Secondary amenorrhea is the absence of normal menstruation in a patient with a previously established cycle and PCOS presents in 30% of cases of secondary amenorrhea ( Smith & Netter, 2018). Therefore, demonstrating this needs to be ruled out. However given the patients presenting symptoms of having regular periods her whole life um-il this change occulted 5 months ago. In addition, family history of PCOS, currently has hirsutism, and is showing signs of acanthosis nigricans which are suggestive of hyperandrogenism leading io a primary differential of POOS.

Differential Diagnosis

Primary Differential Diagnosis #1- PCOS to secondary amenorrhea

Etiology and Clinical findings: PCOS a common endocrine disorder with an etiology that is unknown (Smith & Netter, 2018). Hoy ever, there are studies that have shown there to be a genetic factors and possible auto aomal transmission ( Q mith & Netter, 2018). PCOS does affect 5-10% of women in their reproductive age (McPhee & Papadakis. 2019). It has been noted that POS is linked to increase GnrH and abnormal secretion of FSH and LH resulting in in excess androgen (Smith & Netter, 2018). Therefore, an increase in LA can help with diagnosis of the condition. PCOS is associated with hirsutism, amenorrhea, anovulation, insulin resistance, multicystic ovaries, obesity, risk of diabetes, cardiovascular disease and metabolic syndrome. As per Jarrett et al (2019), Rotterdam Criteria can be used for diagnosis for POOS. This criteria includes androgen production, ovulatory dysfunction and polycystic ovaries. More clinical findings include acanthosis nignicans, acne and apple shaped obesity. In addition, it has been linked to long-term risl- of endometnal cancer.

Rationale Pertinent Positive and negative:

Given the above information this patient presents many clinical findings of POOS. The patient has areas of acanthosis nigricans of thc neck and armpits, increased BMI, hirituism, amenorrhea, elevated cholesterol and a family history of PCOS. Pertinent negative in thi e situation that blood work and pelvic un would have to be done first to confirm diagnosis.

Diagnostic criteria for diagnosis: Please refer to the primary differential plan below

Differential Diagnosis #2- Functional Hypothalamic / Pituitary causes

Etiology and Clinical findings: functional hypothalamic dysfunction are contributing cause of amenorrhea for women. Functional hypothalamic dysfunction is also known as functional hypothalamic GnRH deficiency, which is characterized by a presurned decrease in hypothalamic GnRH secretion (McPhee & Papadakis, 2019). Decrease GnRH can lead to a decrease in gonadotropins. FSH, LH, absence of normal follicular development, anovulatlon and low serum estrogen concentrations (McPhee & Papadakis, 2019). One of the most common causes of secondary amenorrhea is from disturbed hypothalamic—pituitary-ovarian axis from stress, weight loss and or excessive physical exercise(Smith & Netter, 2018).. In addition, such eating disorders such as anorexia nervosa or excessive exercise from athletes. The test to distinguish hypothalamic dysfunction from pituitary diseases, where hypogonadism is also characteristic is related to Gnrh.

According to Smith & Netter( 2018) 35% of cases of secondary amenorrhea is related to functional hypothalan•ic dysfunction. This condition is usually a diagnosis of exclusion, made after ruling out organic diseases. One of the main clinical concems is that it can cause bone loss due hypoestrogenism Another clinical manifestation include weigh, loss or the athlete triad of — amenorrhea, eating disorder, osteoporosis or osteopenia.

Among pituitary disorders that cause secondary amenorrhea. prolactin-secreting pituitary adenomas prolactinomas are tl• most common.

Pertinent Positive and negative: pertinent positive is that the patient does demonstra.? irregular periods and it is important to note that 35% of hypothalamic dysfunctions are associated with secondary amenorrhea. However, Pertinent negative is that we do not have any recent blood work or labs to review. In addition, there has been no change in the pt. 's weight to cause weight loss and thvre has been no indication of stress,

Differential Diagnosis #3- 'Ih•rroid dysfunction

Etiology and Clinical findings: Ihyroid disease can commonly affect the menstrual cycle of women. As per Mc"hee & Papadakis (2019), it has been seen in 35% of women with hypothyroidism and 3.7 % of women with hyperthyroidism(McPhee & Papadakis 2019), The connection between thyroid hormone levels and the menstrual cycle is mainly mediated by thyrotropin-releasing honnone (TRH), which has a direct effect on the ovaries(McPhee & Papadakis, 2019). Additionally abnormal thyroid function can alter levels of sex hormonebinding globulin, prolactin. and gonadotropin-releasing homone. contributing co menstrual dysfunction (McPhee & Papadakis, 2019). Clinical manifestations for women for hypothyroidism and hyperthyroidism include heavy bleeding patterns, amenorrhea, oligomenorrhea, galactorrhea and decreased Certility (McPhee & Papadakis, 2019).

Rationale/ Pertinent Positive and negative: This has to be a consideration given that there has been a change in the patient's menstrual cycle. Pertinent positives in this situation include amenorrhea. Pertinent negative there was no indication of heavy periods before or no abnormal nipple discharge, In addition, no history ofhyoer or hypothyroidism.

Plan of care for Primary differential Diagnosis of PCOS

· A pregnancy test is recommended as a first in evaluating any woman with secondary amenorrhea. Measurement of serum BhCG is the most sensitive test. Urine ana blood work testing shuuld be done to confirm pregnancy.

· Goal of care requires dealing with abnormalities that comes with the condition ofPCOS. This includes dealing with anovulatory infertility, metabolic risk factors, obesity and dyslipidemia.

Testing/Lab:

l. Blood requisition for L] , FSH, prolactin, GnRH, total thyroid screening, ACTH, serum testerone (total) and DHEA. In addition, lipid panel, glucose, HA I c.

Diagnostics Criteria: & Imagining:

2. Tranuvaginal U/S can show ovarian enlargemvnt or presence of multiple small follicles on the ovaries ( pearl of cysts).

3. As per Jarett ( 2019), Rotterdam criteria for diagnosis includes:

a. Oligomenorrhea or anovulation

b. Climcal and biochemical signs of hyperandrogenism

c. Polycystic ovaries

Non-Pharmacology

4. First line therapy for PCOS included weight loss management that can help retum menstrual function In patients with mild or early PCOS. For patients with obeuity weight reduction and exercise can often reverse the metabolic effects (McPhee & Papadakis, 2019).

5. Discu„sion with the patient to review restarting COC therapy to prevent unplanned pregnancy in the event anovulation retums. However. the discussion would be lependent if the patient is interested in pregnancy. If patient is considering pregnancy discussion would then be to review medication that would induce ovulation.

6. E not pursuing pregnancy to manage end ometrial protection from chronic anovulation discussion of resuming COC is first line therapy. In addition, COC provides management for the hirsutism. Consideration for IUD use as it has been effective in minimizing uterine bleeding and endometrial hyperplasia, but not against hirsutism (McPhee & Papadakis, 2019).

7. For management of dyslipidemia includes exercise weightless and monitoring of Lipid profile.

Pharmacology:

8. ICetformin 500 mg PO fi.ice a day( Snith & Netter, 2018)

0 . Spironolactone 25 mg PO three times a day is useful in treating hirsutism (McPhee & Papadakis, 2019).

10. I F not managed with exercise and weight reduction a consideration of using statins is important

I l. COC's are the mainstay of pharmacologic therapy for women with PCOS for managing hyperandrogenism and menstrual dysfunction and For providing contraception.

Surgical treatment: None

Patient Education:

IL. Education should be provided on the importance of monitoring lipid profile and glucose profile (McPhee & Papadakis, 2019).

13. If patient is considermg pregnancy patient will be advised to stop Spironolactone as it is consid ered a category drug for patients of child bearing potential.

l l. Explain to the patient that there is some evidence that women with PCOS have impaired quality of life and higher rates of depression and anxiety when compared with women of' snnilar BMI without PCOS. Therefore, education about stress reduction and ways to manage their psychosocial aspect is impollant.

Follow up:

15. Normal health maintenance once diagnosis is confirmed is important to implement and to monitor lipid panel. glucose, HA I c.

16. Patient IS at risk for diabetes. so ongoing discussion of weight control and exercise.

17, 'Ihe vhronic anovulation seen i n PCOS is associated with an increased risk of endometrial hyperplasia and possibly endometrial cancer. Therefore discussion about rocs as firstline therapy for menstrual dysfunction and endometrial protection ( Jarrett et al, 2019)

18. Discussed the importance of managing this condition to reduce risk factors for type 2 diabetes and cardiovascular disease, therefore, ongoing review of cardiovascular risk

•actors.

References

Carcio, H. A. & Secor, R.M (2015). Advanced health assessmen' Qfwomen. 3 rd ed. New York, New York: Springer Dubli$hlng Co.

Jarrett B.Y., Lin, A-W., Lujan, M (2019). A commentary on the new evidence-basud lifestyle recommendations for patients with polycystic ovary syndrome and potential barriers to their implementation in the united states. Journal 01 the academy of nutrition and dietetics. vol 119(2) 0 05-210

McPhee, S. & Papadakis M. (2019). Current Medical Diagnosis and Treatment.

McGraw-Hill Medical Publishers.

Smith, R. P, & Netter F. H. (2018). Netter's obstetrics and gpnecolog,'. 3rd edition. Philadelphia

PA: Elsevier.