SOAP Note 4 (Womens Health)

Student Name: Maegan Bell

Clinical location patient seen: OBGYN Specialists of Columbus, Dr. Rees
Date of visit: 11/10/2016

Subjective (S)

Patient demographics:
Initials: T.O.
Age: 36
Ethnicity: Caucasian
Gender: Female
Relationship of informant (if not the patient): N/A

Chief Complaint (CC): Irregular periods and weight gain. Patient

was seen on 10/17/2016 for annual Well Woman Exam. At this time,
she voiced the previous complaints. She was sent for a pelvic
ultrasound to rule out polyps and fibroids. She also had lab work done
to evaluate her health status, irregular menses, and rule out anemias
and/or hormonal problems, such as menopause. She is following-up
today for further evaluation and test results.

History of Present Illness (HPI):

How long has this been going on?
2-3 months
When was your last menstrual period?
11/06/2016
How many days in between your cycles?
28, when they were normal
How heavy is the bleeding (e.g. regular, heavy, scant, any flooding)?
heavier than normal recently
What is the flow like throughout your cycle (e.g. how does it start, how
is it midway through, how is it when it ends)?
Starts with spotting then progresses to a heavy flow, and begins
to taper off around day 6-7
How many tampons/pads do you use?
Super tampons on the heavy days, changing around every 3-4
hours
How long are your cycles?
Most recent cycle lasted 7 days
Prior to this period on 11/06/16, her LMP was 10/10/16. Prior to
this she had an episode of bleeding for 7 days with only a two-
week interval between periods.
Are there any accompanying problems (e.g. weight gain, cramping,
bloating, mood changes)?
Denies cramping. She does report a weight gain of 22 lbs. over
the past 2 years. She admits to fatigue, hot flashes and night
sweats.
At what age did you first get a period?
11 years old
Have you had these kind of period issues before?
Not until about 3 months ago
Do you have a history of irregular menstrual cycles?
No
Are you sexually active?
Yes, with husband
What are you using for birth control?
Tubal Ligation
Are you using any hormones?
No
Are you having any symptoms of menopause (e.g. vaginal dryness, hot
flashes or night sweats)?
Hot flashes and night sweats
What was the result of your last PAP test?
Normal on 10/27/2016
Do you still have a uterus?
Yes
Do you have any bleeding disorders?
No
Are you taking any anticoagulants?
No
Any chance you could be pregnant?
No
Have you recently had a baby?
Last pregnancy was in 2010
At what age did your mother and/or grandmother go through
menopause?
Grandmothers in their 50s, she thinks
Have you had any changes in your diet recently?
No
Have you had any stressful events in your life recently?
No
Do you suffer from depression?
Yes, taking Cymbalta
How would you describe your eating habits and dietary practices?
Tries to eat healthy, but sometimes falls short.
Can you describe what you eat in a typical day?
 Doesnt eat breakfast most days, just has a cup of coffee. Salads
for lunch, if possible. Her and her husband try to cook and grill at
home as much as possible for dinner.
How would you describe your level of physical activity?
Runs around with her 3 kids, but does not regularly exercise.
Has the weight gain been sudden or gradual?
Over 2 years, reports 22 lbs. increase

Past Medical History (PMH):

Health Status:
Good
Allergies:
NKDA, no known food or contact allergies
Previous acute or chronic illnesses:
Depression
o Onset: years ago after the death of her mother
o Treatment: Cymbalta 30 mg daily
o Well-controlled on medication
o Took Prozac years ago, before switching to Cymbalta to try
and better manage her symptoms.
Injuries:
None reported
Childhood illnesses:
Asthma
o Resolved. She reports no respiratory issues as adult.
Current Medications:
Cymbalta
o 30 mg capsules daily
o History of depression
o Taken for years with no side effects or issues
o Seems to work well
o Took Prozac years ago, before switching to Cymbalta to try
and better manage her symptoms.
Immunization Status:
Influenza
o Received in October 2016 at her primary care physicians
office
o Normally gets a flu shot every year
Td/Tdap
o According to records, received Tdap during last pregnancy
in 2010
Varicella
o Had chicken pox as a child per patient. According to
records, varicella titer (IgG ELISA) positive for immunity.
 MMR
o Had vaccine as a child per patient. Records indicate a
second MMR was given in 2000 after her first C-Section for
lack of immunity to Rubella.
Screening/ Diagnostic Tests:
Cervical Cancer Screening
o Grade A (recommended) The USPSTF recommends
screening for women age 21 to 65 years with cytology (PAP
Smear) every 3 years, or for women age 30-65 years who
want to lengthen the screening interval, screening with a
combination of cytology and HPV testing every 5 years.
o Last PAP Test Thin Prep was 10/27/16 (Negative for
intraepithelial lesion or malignancy)
o She does not need to repeat her PAP until 10/2019
HIV screening
o Grade A (recommended) - The USPSTF recommends that
clinicians screen for HIV infection in adolescents and adults
aged 15-65 years.
o Due for screening
High Blood Pressure Screening
o Grade A (recommended) The USPSTF recommends
screening for high blood pressure in adults aged 18 and
older.
o BP in office today was 127/88.
o Patient encouraged to check BP at home periodically and
write down the dates and measurements. Home monitoring
is also encouraged by the USPSTF.
o No history of hypertension, and no reports of headaches or
dizziness.
Hospitalizations
Caesarian Sections (C-Section) x3 2000, 2002, 2010
o Admitted for childbirth and monitoring
o Her first baby was breech, requiring C-Section. Her next
two C-Sections were scheduled.
o No complications and good outcomes.
Past Surgical History (PSH):
C-Sections x3 2000, 2002, 2010
o First C-Section in 2000 was due to her son being in the
breech position. Subsequent scheduled C-Sections were
done in 2002 and 2010 due to prior C-Section, and risks
associated with VBAC.
o All C-Sections went well. Patient reports no
complications, and all healthy babies.
Tubal Ligation 2010
 o After her third child, patient underwent tubal ligation for
contraceptive reasons.
o No complications.

Family History (FH):

Paternal Grandfather (Deceased, Age: 72 )
Cause of death: Heart attack
Paternal Grandmother (Deceased, Age: 81)
Cause of death: old age
Poorly controlled diabetes when alive
Father (Living, Age 67)
Hypertension
Maternal Grandfather (Deceased, Age 90)
Cause of death: unknown
History of Alzheimers
Maternal Grandmother (Deceased, Age 52)
Cause of death: breast cancer
Mother (Deceased, Age 40)
Cause of death: MVA
Sister (Living, Age 38)
Depression, migraines

Social History (SH):

Marital Status:
Married for 17 years to her husband
Children:
She has three children, two boys (age 16 and 14) and one girl
(age 6)
Occupational history:
Stay-at-home mother
Level of education
High School Diploma
Exercise
Runs around with her 3 kids, but doesnt report any formal
exercise routine with sustained aerobic workouts.
Diet
24 hour recall AM: cup of coffee, Lunch: Drive-thru salad from
Chick-fil-A and lemonade, Dinner: Grilled steak and asparagus
with a coke.
She states she tries to eat healthy by grilling, eating 2-3
portions of fruits and vegetables a day, and drink plenty of water.
She does admit to falling short sometimes
Safety
House is equipped with smoke alarms
 She wears a seat belt always
All firearms in the home are in a locked cabinet
Living arrangements
Lives with her husband and 3 children in a two-story dwelling
Hobbies
Reading, photography
Travel
Only recent travel is to visit in-laws out of state.
She has never traveled outside the country.
She has not been around anyone who has recently (within the
past 6 months) traveled outside the country to her knowledge.
Religious preference
Methodist
Use of tobacco
Never smoker
Use of alcohol
Socially, may have a glass of wine or beer
Use of illegal drugs
Denies
Insurance
Private insurance through BCBS
Ericksons Developmental Stage
Intimacy Versus Isolation
o Intimacy is reaching out and using the self to form a
commitment to and an intense, lasting relationship with
another person or even a cause, an institution, or creative
effort. Intimacy does include sexual intercourse, but it also
means more than just physical contact. With the intimate
person, the young adult is able to regulate cycles of work,
recreation, and procreation (if chosen), and to work toward
satisfactory stages of development for offspring and the
ongoing development of self and the partner. Although the
person shares his or her identity with another for mutual
satisfaction or support, he or she does not fear loss of
personal identity. Each does not absorb the others
personality. Isolation, then, would be the inability to be
intimate, spontaneous, or close with another, thus
becoming withdrawn, lonely, and conceited, and behaving
in a stereotyped manner. The person may not marry or
sustain close friendships.
o T.O. demonstrates intimacy. She is in a long-term
relationship (17 years) with her husband. She reports being
happy, and they have 3 children together. She enjoys being
able to stay home and help raise her family. She has a
 good social life and multiple close friends. She is sexually
active with her husband on a regular basis. She is able to
manage her needs with the needs of her husband and
children. She has a history of depression, triggered by the
death of her mother, but her symptoms are well controlled
on medication.

Review of Symptoms (ROS):

General:
Weight gain, fatigue. Denies weight loss, denies fever, denies
chills.
Eyes:
Denies blurred vision, excessive tearing, pain, or trauma.
Last eye exam six month ago, report 20/20 vision in both eyes,
does not wear glasses or contacts.
Ears, nose, mouth and throat:
Denies changes in hearing. Denies changes in smell. Denies
nasal discharge, or bleeding. Denies recent or previous injury to
ear, nose or throat. Last dental exam was 2 months ago. No
dental carries reported. She does have a permanent crown on
the upper left second molar. She reports brushing and flossing
daily. Does not smoke or use oral tobacco products. Denies sore
throat, hoarseness or dysphagia.
Cardiovascular:
Denies regular sustained aerobic exercise routine. Denies history
or diagnosis of murmurs, denies chest pain, palpitations,
swelling, or shortness of breath. She denies high blood pressure,
and does not report symptoms of elevated BP such as headache,
dizziness, or changes in vision. No prior EKG at this office.
Respiratory:
Denies history of pneumonia or tuberculosis. She has never
smoked. Denies difficulty breathing, cough, wheezing or
hemoptysis. No prior chest x-ray per patient.
Gastrointestinal:
Denies heartburn, abdominal pain, changes in bowel habits or
stools, nausea, vomiting, diarrhea, constipation or bleeding per
rectum. Denies hemorrhoids. She does try to eat healthy, and
consume 2-3 portions of fruits and vegetable per day. She also
tries to drink plenty of water.
Genitourinary:
Denies difficulty urinating, denies pain with urination, denies
urinary frequency, urinary urgency or burning. She is sexually
active with her husband. Denies pain with intercourse. Tubal
ligation for contraception. Denies abnormal vaginal discharge.
 Denies vaginal itching. Denies history of STDs. Irregular cycles
for the past 2-3 months. Per patient her cycles began at 11 years
old and were regular, lasting about 7 days, with 28 days between
each cycle. She reports increase in bleeding within the past few
months during her periods, having to change her tampon every
3-4 hours. She denies dysmenorrhea. But within the past 2-3
months, her cycles have been occasionally irregular, with
episodes of heavier bleeding lasting 7 days, but with 2-week
intervals at times between periods, instead of normal 28 days.
LMP 11/06/16. Denies current HRT. Last PAP test was 10/27/16
and normal. She is a G 3 P 3. She has had 3 C-Sections.
Musculoskeletal:
Denies regular sustained aerobic exercise routine. She does do a
lot of running around with her children. She does wear a seat
belt in vehicles. Denies joint pain, swelling, decrease in range of
motion, or numbness to extremities.
Integumentary:
Denies rashes, hair loss, easily bruising. Denies nail deformities.
Neurologic:
Denies muscle weaknesses, parasthesias, and involuntary
muscle movements or tremors. Denies loss of memory, seizures,
and/or headaches.
Psychiatric:
Depression. Denies irritability, mood changes, anxiety, insomnia,
and/or suicidal thoughts.
Endocrine:
Weight gain, hot flashes, and night sweats. Denies polydipsia,
polyuria, and/or polyphagia.
Hematologic/ lymphatic:
Fatigue, unusual vaginal bleeding. Denies unusual bruising.
Denies swollen or tender glands.
Allergic/ immunologic:
Denies seasonal allergies or prior allergy testing. Denies history
of exposure to blood or bodily fluids. Denies immunosuppression.
Denies prior use of steroids.

Objective (O):

Physical Exam:

Constitutional:
A 36-year-old white, well-nourished, pleasant female presents
today for follow-up of ultrasound and lab work. She is alert and
oriented, and seated on the exam table.
Vital signs
 o Temp: 97.4 degrees F (Tympanic)
o BP: 127/88 (seated, left arm, manual)
o Pulse: 68
o Pulse ox: 98% (Room Air)
o RR: 16
o HT: 60
o WT: 143 lbs.
o BMI: 27.9 kg/m2
A BMI of 25.0-29.9 signifies her as overweight. A
normal BMI is 18.5-24.9.

HEENT:
Head and neck symmetric with no lumps, lesions, or tenderness.
No drooping of the face or eyelids. Neck moves freely with no
pain. Thyroid normal with no palpable nodules. Conjunctivae
clear and sclera white. PERRLA. Nose symmetric with no
deformities. Mouth mucosa and gingivae pink with no masses.
Moist membranes noted. Tongue smooth and pink and midline
with no lesions. No lymphadenopathy.
Cardiovascular:
No visible pulsation. Apical pulse palpated over the fifth
intercostal space at the midclavicular line with no thrill noted.
Heart rate 68, with regular rhythm, blood pressure 127/88.
Normal S1 and S2 present, no murmurs, rubs or gallops noted.
No JVD or carotid bruits. No edema or visible varicose veins in
lower extremities.
Respiratory:
AP:L ration 2:1. Respiratory rate 16 and nonlabored. Trachea
midline with no masses, lesions, or tenderness. Thoracic
expansion and tactile fremitus equal on both sides. Bilateral
breath sounds CTA, no adventitious breath sounds noted.
Percussion reveals resonance of all lung fields.
Gastrointestinal:
Abdomen round and symmetric. Bowel sounds active in all four
quadrants with no bruits heard. Tympany in all four quadrants.
No CVA tenderness. Soft to palpation with no masses or
tenderness. Deep palpation with no masses noted. Low,
transverse abdominal incision scar is well healed.
Genitourinary:
No lesions, ulcerations, or masses noted on external genitalia,
perineum, or rectum. Hair is evenly distributed throughout. The
clitoris is midline, approximately 1 cm in length, smooth, without
lesions, ulcerations or masses. The urethral orfice is midline,
pink, smooth and patent. No urine leakage with cough. The
vaginal opening is pink and round, with no visible bruising, tears,
 lesions, ulcerations or masses. No vaginal discharge. Upon
examination with speculum, parous cervix appears intact, pink,
moist, round and centrally positioned with a small opening in the
center. No discoloration, ulcerations, lacerations, indurations or
masses visualized. Endometrial biopsy consent obtained and
procedure preformed, with adequate amount of tissue obtained.
Uterine sound measurement approximately 8 cm. Patient
tolerated the procedure well. Bimanual palpation revealed a firm,
smooth, parous cervix and retroverted uterus. No pain or
tenderness with palpation of the cervix, fornices, uterus, and
ovaries. No masses, nodules, or bulges noted with bimanual
palpation. Rectovaginal exam deferred. No visible hemorrhoids.
Integument/ lymphatic:
Skin intact, pink in color, warm to touch, smooth and even with
no rashes or bruising. No suspicious looking lesions present. Hair
is evenly distributed throughout on the head. No pest
inhabitation. Nail beds clean with no clubbing or deformities. No
lymphadenopathy noted.
Neurologic:
Alert and oriented, no focal deficits, motor strength normal in
upper and lower extremities, sensory exam intact. No
documented history of seizures or headaches.
Psychiatric:
Cooperative. Appropriate mood and affect, normal judgment.
Hematologic/ lymphatic/ immunologic:
No lymphadenopathy. No bruising.

Diagnostic Testing:

1. Transvaginal Pelvic Ultrasound (Completed 11/01/16)

a. Rule out uterine fibroids and/or cervical polyps
b. A TVUS examines the reproductive organs for
abnormalities, and will help determine the source of
irregular bleeding.
c. Results: Retroflexed uterus noted. Appears homogeneous
and WNL. Small amount of free fluid seen in the posterior
cul de sac and anterior cul de sac. A simple cyst is noted
on the left ovary measuring 2.5 x 1.9 x 2.2 cm, also a left
ovarian complex cyst with multiple thin septations
(hemorrhagic?) is noted measuring 1.9 x 1.5 x 2.6 cm. Free
fluid is also noted adjacent to the left ovary. The
endometrium appears thickened with a small amount of
fluid seen within it.
 i. Uterus Length 8.05 cm, width 4.85 cm, height 4.54
cm, volume 92.99 cm3, endo. Thickness 12.54 mm,
cervix length 3.47 cm
ii. Left ovary length 4.36 cm, width 3.68 cm, height
2.90 cm, volume 24.41 cm3
iii. Right ovary length 2.98 cm, width 2.31 cm, height
1.96 cm, volume 7.06 cm3
2. Complete Metabolic Panel (Completed 10/27/16)
a. This will help measure kidney function, liver function,
glucose level, and electrolyte levels. This test could help
detect issues such as diabetes, liver failure, hepatitis,
kidney failure, dehydration, and other metabolic diseases.
This is a normal screening test that should be done
routinely, but is also warranted today due to the patients
symptoms of fatigue, weight gain, and irregular menses.
b. Results: Na 139 (135-147), K+ 4.6 (3.5-5.0), Cl 99 (95-107),
CO2 25 (23-29), Glucose 80 (65-110), BUN 9 (7-20), Cr 0.72
(0.57-1.0), BUN/Creat Ratio 13 (6-22), eGFR Non-African
American 108 (>60), Ca 9.7 (8.5-10.2), ALT 12 (10-35), AST
19 (0-40), Protein 7.0 (6.0-8.4), Albumin 4.6 (3.5-5.5),
Bilirubin, Total <0.2 (0.0-1.2), Alk phos 59 (44-147)
3. Vitamin B12 (Completed 10/27/16)
a. Rule out Vitamin B12 deficiency as cause of fatigue
b. Results: 443 (211-946)
4. Vitamin D (Completed 10/27/16)
a. Rule out Vitamin D deficiency as cause of fatigue
b. Results: 14.7 L (30-100)
5. Thyroid Panel (Completed 10/27/16)
a. Rule out thyroid dysfunction as cause of irregular menses,
weight gain, hot flashes, and fatigue
b. Results: TSH 1.630 (0.450-4.500), T4 7.3 (4.5-12)
6. FSH (Completed 10/27/16)
a. Rule out hormonal related causes for dysfunctional uterine
bleeding, determine menopausal status
b. Results: 2.6 (1.7-7.7 Luteal phase)
c. LMP in October was 10/10/16
i. Follicular phase approximately 10/10-10/24
ii. Ovulation occurring around 10/24
iii. Luteal phase approximately 10/24 11/7
iv. Lab work drawn 10/27
7. Estradiol (Completed 10/27/16)
a. Rule out hormonal related causes for dysfunctional uterine
bleeding, determine menopausal status
b. Results: 184.6 (43.8-211 Luteal phase)
c. LMP in October was 10/10/16
i. Follicular phase approximately 10/10-10/24
 ii. Ovulation occurring around 10/24
iii. Luteal phase approximately 10/24 11/7
iv. Lab work drawn 10/27
8. Testosterone (Completed 10/27/16)
a. Rule out hormonal related causes of dysfunctional uterine
bleeding, determine menopausal status
b. Results: 12 (8-48)
9. Complete Blood Count (Completed 10/27/16)
a. Rule out infection or secondary anemias. Also good to have
as a baseline.
b. Results: WBC 6.8 (3.4-10.9), RBC 4.73 (3.77-5.28), Hgb
12.2 (11.1-15.9), Hct 38.9 (34.0-46.6), MCV 82 (79-97),
MCH 25.8 L (26.6-33.0), MCHC 31.4 L (31.5-35.7), RDW
14.7 (12.3-15.4), Platelets 374 (150-379), Neutro % 58 (54-
62), Lymphs % 28 (25-33), Mono % 7 (3-7), Eos % 3 (1-3),
Basos % 0 (0-1).
10. PAP Test Thin Prep (Completed 10/27/16)
a. Preformed as part of her annual well woman exam for
recommended cervical cancer screening.
b. Results: Negative for intraepithelial lesion or malignancy
11. Urine Pregnancy test (Completed 10/27/16)
a. Rule out pregnancy
b. Results: Negative
12. Factor VIII coagulant activity (Not done)
a. Could have been preformed to rule out von Willebrands
Disease
13. PT and aPTT (Not done)
a. Could have been preformed to rule out other diseases of
hemostasis, such as von Willebrands Disease
14. Endometrial Biopsy (Pending)
a. Determine presence and type of endometrial hyperplasia
b. The treatment recommendations will depend on results,
typical or atypical pathology, based on increased risks of
uterine cancer.
i. Progestin therapy vs. surgical hysterectomy

Assessment/ Analysis (A):

Visit Level-
99214 (detailed, established, 25 minutes office outpatient visit)

Differential Diagnoses:

Priorit Differential Diagnosis Supportive Refuting Data

y# Date
7. Uterine Fibroids/ Menometrorrhag Denies pelvic
 leiomyomas ia (Irregular pressure,
menses, Heavy bloating,
bleeding). constipation or
Multiparous. urinary
Nonsmoker. Can frequency.
be Denies
asymptomatic. dyspareunia.
Denies
dysmenorrhea.
No history of
reproductive
issues. Uterus
not enlarged
on exam. TVUS
negative for
leiomyomas.
8. Adenomyosis Menometrorrhag Denies
ia (Irregular dysmenorrhea.
menses, Heavy Uterus normal
bleeding). on examination
Multiparous. Can (not enlarged
be or boggy).
asymptomatic. TVUS did not
TVUS shows show cystic
thickened collections in
endometrium. myometrium.
2. Endometrial Hyperplasia Overweight. Multiparous
Family history of (nulliparity is a
breast cancer. risk factor). No
Menometrorrhag history of DM,
ia (Irregular hypertension,
menses, Heavy PCOS,
bleeding). TVUS tamoxifen
demonstrated therapy.
thickened
endometrium.
Age >35.
Caucasian race.
3. Endometrial malignancy Common in 36 years old
Caucasians. (median age
Early menarche for dx is 60,
(age 11). rare under the
Menometrorrhag age of 40).
ia (Irregular Multiparious
menses, Heavy (nulliparity is a
bleeding). risk factor). No
 history of DM,
hypertension,
tamoxifen
therapy. Denies
pelvic pain. No
masses on
examination or
TVUS. Denies
weight loss. No
laboratory
evidence of
malignancy.
10. von Willibrand Disease Menometrorrhag Denies easily
ia (Irregular bruising.
menses, Heavy Denies
bleeding). frequent
nosebleeds or
bleeding of the
gums. No
bruising on
exam. No
family history
of hemostasis
disorders. CBC
did not
demonstrate
significant
anemia.
9. Perimenopausal Menometrorrhag 36 years old,
ia (Irregular typically occurs
menses, Heavy later. Hormone
bleeding). levels are
Irregular normal. No
menses. Fatigue. reports of
Hot flashes. trouble
Endometrial sleeping,
thickening on vaginal
TVUS. dryness,
decreased
libido or mood
swings.
14. Ovarian cysts Irregular Denies
menses. Can be abdominal
asymptomatic. achiness or
Visualized on pain.
TVUS on the left
 side. Not on
OCPs.
4. Cervical Intraepithelial Mostly occurs in No history of
Neoplasm patients <50. HPV or
Multiparity is a abnormal PAP
risk factor. smears.
Menometrorrhag Nonsmoker. No
ia (Irregular family history
menses, Heavy of cervical
bleeding). cancers. No
reports of
postcoital
bleeding. No
pelvic pain. No
unusual
vaginal
discharge.
Normal PAP on
10/27/16.
Normal cervix
on
examination.
5. Cervical polyps Menometrorrhag No leukorrhea.
ia (Irregular No polyps
menses, Heavy visualized or
bleeding). palpated on
Multiparous. exam.
6. Endometrial polyps Menometrorrhag TVUS did not
ia (Irregular demonstrate
menses, Heavy any masses.
bleeding).
Endometrial
thickening on
TVUS. Age >20.
1. Pregnancy threatened, Menometrorrhag Negative urine
incomplete, or missed ia (Irregular pregnancy test.
abortion and ectopic menses, Heavy No pregnancy
bleeding). visualized on
Fatigue. Weight TVUS. History
gain. Sexually of tubal
active. ligation for
contraception.
11. Hypothyroidism Menometrorrhag No family
ia (Irregular history of
menses, Heavy thyroid
bleeding). disease.
 Fatigue. Weight Normal thyroid
gain. functioning on
Depression. labs. No
masses,
nodules or
goiters on
exam. No
symptoms of
decreased
appetite, hair
loss, dry skin,
emotionally
labile,
forgetfulness,
or constipation.
12. Endometriosis Early menarche. No family
Menometrorrhag history. Denies
ia (Irregular abdominal or
menses, Heavy pelvic pain. No
bleeding). history of
infertility. No
dyspareunia.
No
dysmenorrhea.
13. PCOS Menometrorrhag Denies
ia (Irregular oligomenorrhe
menses, Heavy a or secondary
bleeding). amenorrhea.
Overweight. No signs of
Endometrial excessive hair
thickening on growth or
TVUS. acne. No family
history. No
history of DM.
Normal glucose
level. Normal
hormone
levels. No
history of
infertility. TVUS
showed
evidence of x2
cysts but
ovaries were
not
polycystic.
15. Vitamin B12 and/or D Fatigue. Low Laboratory
deficiency serum vitamin D serum B12
levels. value WNL,
Depression. normal MCV.
No history of
underlying
disease
associated with
Vit. B12 or Vit
D deficiency.
No history of
musculoskeleta
l complaints.

Definitive Diagnoses:

Acute, self-limited problems

o Endometrial thickening and menometrorrhagia, probable
diagnosis of endometrial hyperplasia
ICD 10 R93.8, N92.1, N85.0
Endometrial thickening could be due to secretory
phase of menstrual cycle occurring
Biopsy to confirm endometrial hyperplasia and rule
out malignancy
o Left ovarian simple cyst
ICD 10 N83.29
Most likely follicular in nature
o Left ovarian hemorrhagic cyst
ICD N83.20
Most likely corpus luteum in nature
o Vitamin D deficiency
ICD 10 E55.9
o Probable perimenopause
ICD 10 N95.9
o Procedure Codes
TVUS - 76830
Endometrial Biopsy - 58100
PAP thin prep - 88142
Chronic health problems
o Depression
ICD 10 F33.9
Well controlled on oral anti-depressant medication
Health Maintenance
o Overweight
 ICD 10 E66.3
Worsening. Patient has gained 22 lbs. over the past 2
years. The patient needs to participate in sustained
aerobic exercise for 30-60 minutes per day, 3-5 times
per week. She also may have had decreased energy/
tolerance for exercise due to Vitamin D deficiency
and menometrorrhagia.

Plan (P):

1. Endometrial Thickening and menometrorrhagia, probable

diagnosis of endometrial hyperplasia
a. Psychosocial interventions/ education: Educate the client
about normal menstrual cycles and possible reasons for
her abnormal pattern. Be generous with reassurance.
Menstrual calendars are helpful with instructions given
about documenting any bleeding or spotting, days and
dosages of medications, pad or tampon count, and
associated symptoms, such as dysmenorrhea (there are
many apps available on your phone). By providing
information about expected bleeding patterns on
discontinuation of medications, you will help the client to
avoid fears or recurrence or treatment failure.
b. Start medroxyprogesterone acetate for 10 days. If
endometrial biopsy comes back without atypia, continue
therapy monthly for 3-6 months. At that time, repeat
endometrial biopsy, if hyperplasia has resolved and patient
is asymptomatic, therapy may be discontinued.
i. Indications: In hyperplasia without atypia, cyclical
progestin therapy is the recommended choice in
women not seeking contraception.
ii. MOA (brief): A synthetic form of progesterone
induces EH regression, prevents future EH
development by preventing overgrowth in the uterine
lining and is protective again endometrial cancer, by
combatting unopposed estrogen.
iii. Dosage: 10 mg orally for 10 days
iv. Brand name: Provera
1. Cost (10 day supply): Walmart $42.09, Winn-
Dixie $43.72, Walgreens $45.69
v. Generic: medroxyprogesterone
1. Cost (10 day supply): Walmart $4.00, Winn-
Dixie $4.00, Walgreens $5.00
 vi. Side effects and adverse reactions most commonly
reported include spotting, weight gain, fatigue,
depression, or acne.
vii. Client teaching: Inform the client about the
possibility of bleeding being heavy when medication
is completed. Emphasis should be placed on the
importance of taking the medication to treat and
prevent endometrial hyperplasia and prevent cancer.
Client should report any abnormal bleeding or
absence of withdrawal bleeding.
c. Endometrial biopsy done today in office to rule out
hyperplasia and endometrial cancer
i. Hyperplasia with Atypia consider hysterectomy
ii. Without atypia continue medroxyprogesterone
therapy
iii. Client education: Spotting may occur after biopsy
and is normal. NSAIDs can be used for discomfort
associated with procedure.
d. She is also going to start OTC iron to prevent developing
anemia as well due to heavy bleeding and decreased MCH,
MCHC levels.
2. Left ovarian cysts
a. Expectant management - Repeat TVUS in 8 weeks for re-
evaluation of cysts
b. If increasing in size, >6cm, and persistent or symptomatic,
laproscopic cystectomy may be warranted
3. Vitamin D deficiency
a. Start ergocalciferol 50, 000 IU/week for 8-12 weeks
b. Recheck Vitamin D levels after completion of therapy
c. Treatment of VDD in obesity, especially those who are
obese and depressed, improves depressive symptoms and
may improve weight loss.
4. Probably perimenopause
a. Recheck hormone levels in 6 months
b. Discuss hormone replacement therapy options for
symptom control
5. Depression
a. Continue taking Cymbalta as prescribed and follow-up with
PCP
b. Treatment of VDD in obesity, especially those who are
obese and depressed, improves depressive symptoms and
may improve weight loss.
6. Overweight
a. Counseled on:
i. 1800-calorie diet, need to increase consumption of
fiber from fruits, vegetables and whole grains,
 decrease consumption of foods or beverages high in
refined sugars or caffeine, and drinking more water.
ii. Need for sustained aerobic exercise for 30-60
minutes per day, 3-5 days a week
b. Treatment of VDD in obesity, especially those who are
obese and depressed, improves depressive symptoms and
may improve weight loss.

Follow-up: The office will call the patient with the results of
endometrial biopsy, and if warranted, bring her in earlier to
discuss surgical treatment options. Otherwise, office visit one
week after U/S (8 weeks from now) to review results (with
regards to ovarian cysts and endometrial thickening re-
evaluation) and discuss period regularity with progesterone
therapy.

Other health promotion interventions include:

Encourage good sleep hygiene by reducing caffeine intake,
getting enough exercise, and maintaining a regular bedtime
schedule, to reduce fatigue.
Maintain a health relationship with your spouse by spending time
together, giving priority to your spouse and the home, being
faithful, giving positive reinforcement, properly managing
money, dealing with crises in a positive way and remembering
that a good marriage promotes health and longevity and reduces
stress.
Encourage the continued use of seat belts when operating motor
vehicles, as this is a major cause of accidental death in young
adults.
Counsel on health promotion screenings such as
o Blood pressure measurement, baseline and periodically.
Helpful to measure at home and keep a log for your
provider.
o Calculation of BMI and estimated target heart rate for
exercise.
o Dental examination and cleaning twice a year along with
daily brushing and flossing to promote good oral hygiene
and prevent periodontal disease or dental caries.
o Chest x-ray and EKG once as a baseline in adulthood.
o Breast Self-Exams at home to encourage awareness, skill,
and detect possible malignant changes earlier.
Mammography testing should begin being preformed at
age 40 for breast cancer detection.
o Consider HIV screening, as recommended by the USPSTF.
Resources:

Callahan, T.L. (2016). Tarascon OB/Gyn pocketbook. Burlington, MA:

Jones & Bartlett.

Murray, R.B., Zentner, J.P., & Yakimo, R. (2009). Health promotion

strategies through the life span, (8th ed.). Upper Saddle River, NJ:
Pearson.

Uphold, C.R. & Graham, M.V. (2013). Clinical guidelines in family

practice, (5th ed.). Gainesville, FL: Barmarrae.

Youngkin, E.Q. & Davis, M.S. (2004). Womens health: A primary care
clinical guide, (3rd ed.). Upper Saddle River, NJ: Pearson.