NURS 6025 Week 9 Essay Assignment
Comprehensive Patient Assessment
The multifaceted nature of ladies’ well being is one that mirror the assortment and tremendous changes she is encountering in her life. As a provider, we should recognize those progressions among our female patient populace which can comprise of different societies, geologies, and social orders. We will offer the best fitting consideration required by every patient as per their individual needs. For this paper, I will completely audit a patient assessment that spotlights on an individual patient that I observed this quarter. NURS 6025 Week 9 Essay Assignment
Patient’s Current Health Status
KM is a 21-year-old, married Caucasian female who has been with her significant other since the beginning of their 10th grade year of high school. She has a history of PCOS and hyperthyroidism and has not had consistent periods every month. She has presented to the office today for a requested annual exam, to discuss results of recent CBC, CMP and TSH that was obtained at her primary care physician’s office and to review her options for her amenorrhea.
Her last menstrual cycle was 5 months ago on February 1, 2019. Her cycles have never been normal, and reports that she does not have a period every month. She is sexually active with one male partner for the past 5 years. She current does not use any method of birth control and/or protection against any STI’s. She denies any problems and does not have any complaints regarding her sexual activity. NURS 6025 Week 9 Essay Assignment
Patient History
This young ladies’ health history includes depression, hypothyroidism and PCOS. She currently takes 75mg of Effexor daily which controls her depression and 75mcg of Levothyroxine daily for her hypothyroidism, which adequately maintains her TSH at appropriate levels. She is allergic to latex, metformin and sulfur which all cause a diffuse rash all over her body. She does not have any food or environmental allergies. She denies any previous surgeries.
KM has reported that she has previously had the HPV vaccine by the age of 15 and received the influenza vaccine last season. She has never had a PAP for which she will receive in the office today and has never had a mammogram. Per the guidelines of ACOG, she will not have to complete a mammogram until the age of 40.
KM’s family history consists of breast cancer (mother/grandmother), DM (maternal grandmother), thyroid disorder (maternal grandmother) and HTN (maternal grandmother). No other members of her family have any significant health history that she aware of. Family support is available through her grandmother, parents and spouse. Her husband works long hours as an electrician but is home at nights.
Gynecological and Obstetric History
Per patient report, she has never been pregnant but has been trying for a few years; G0 P000. She was told by a previous physician that due to her PCOS it may be very difficult for her to become pregnant and that her periods may be “all over the place.” She has not used any form of contraception for this reason and has never used any barriers to STI’s. She reported that she has only been with one personal sexually. She began her period at age 11 and it was normal for the first few years. She does not report a heavy flow and when she has a period it can last anywhere from 3-7 days. Cramping is minimal and she does not have to take any medication during that time.
Social History
Patient is a 21-year-old female who graduated high school a few years ago but never had plans of attending college. She has never used alcohol or illicit drugs. She did try smoking cigarettes at one time but did not “pick up the habit.” She commutes to and from work by driving a motor vehicle. She reports the utilization of a safety belt while driving and does not use her mobile device while driving that vehicle. She walks occasionally when it’s nice outside but does not do any strenuous activity. She sleeps approximately 6-8 hours per night; denies any issues staying asleep although does have some problems falling asleep. NURS 6025 Week 9 Essay Assignment
Review of Systems
General: No unexplained weight loss or gain, no decreased appetite, no chills, no fever or fatigue.
HEENT: No blurred or loss of vision, no loss of hearing, hearing difficulty or ringing in ears, no
congestion, rhinorrhea, sore throat or hoarseness.
Integumentary: No changes in skin such as rashes, dryness or persistent itching, breasts are symmetrical and firm with no lumps.
Respiratory: No SOB, wheezing, rhonchi or rales, no cough or sputum production
Cardiovascular: No chest pain, palpitations or extremity edema; no pain with walking
Gastrointestinal: No change in bowel habits, indigestion, nausea/vomiting or diarrhea. No
abdominal pain or tenderness, no decrease in appetite.
Genitourinary: No burning with urination, no itching, reports labial/vaginal pain. Last menstrual cycle – 2/1/2019, last Pap – none, Last breast exam – none
Neurological: No dizziness, LOC or headaches. Moves all extremities without tremors
Psychiatric: No mental illness, depression or anxiety
Musculoskeletal: No muscle or joint pain
Hematologic: No anemia, bleeding, not easily bruised, no history of blood transfusions
Lymphatics: No cervical lymphadenopathy, no history of splenectomy
Endocrinological: No heat or cold intolerances, no sweating, no polyuria or polydipsia
Allergies: No history of asthma, hives, eczema or rhinitis
Physical Exam
General exam reveals clean, well-appearing/well-nourished, female who is AOx4, with no distress noted. Vital signs are as follows: temp 97.2 orally, HR 96, RR 17, BP 128/60 in the right arm, SpO2 is 98% on room air. Height 5’4”, weight of 263lbs with a BMI of 45.1.
PERRLA, ears clear, no rhinorrhea, erythema to throat, hoarseness in voice, or cervical lymphadenopathy. Skin intact, no rashes or dryness. Lungs are clear to auscultation bilaterally, no rhonchi, wheezing or rales, + cough, no sputum production. Heart regular rhythm, rate without murmur or gallop, no extremity edema. Abdomen Soft, nontender, bowel sounds present x4.
External Genitalia is normal, pink, no lesions, masses, or trauma noted. Hair
distribution even. Urethra: no irritation noted, midline, Vagina: healthy pink mucosa, no gross lesions, clear discharge noted. Cervix: pink, no lesions, the OS is closed. No cervical motion tenderness. Uterus: small, no tenderness on palpation, anteverted, freely movable, no masses or tenderness palpated. The bladder is nontender to palpation. The anus is free of hemorrhoids and is otherwise normal.
Diagnostics
Urine pregnancy test was performed, and results were negative. No other diagnostic tests needed at this time. US previously performed and blood work recent obtained from PCP office.
Differential Diagnoses
KM was seen in the office for an annual exam, lab reviews and interventions for her amenorrhea. Differential diagnoses for her amenorrhea could include pregnancy, PCOS, & thyroid disorder. Pregnancy is a possibility due to her not having her menstrual cycle for 4 months. As pregnancy being one of the main causes of secondary amenorrhea, a pregnancy test was performed and resulted negative. Therefore, that can be ruled out. NURS 6025 Week 9 Essay Assignment
Polycystic Ovarian Syndrome could be a cause for her amenorrhea. Polycystic ovary disorder (PCOS) is the most well-known hormonal issue among ladies of reproductive age. PCOS makes a lady’s body produce excessive measures of androgens or testosterone, hormones that are related with male sex attributes and reproduction (National Women’s Health Network, 2015). PCOS upsets the equalization of both follicle-stimulating hormone (FSH), the hormone that makes the follicle and egg develop and luteinizing hormone (LH), the hormone that makes the follicle discharge the egg. The result is that a small cyst is formed in the ovary, which disrupts the woman’s hormonal balance. KM’s ultrasound of the ovaries appeared normal. She did have a slightly elevated testosterone level (which is her baseline on all labs) but all other hormone levels were normal.
Hypothyroidism could also be a cause for her amenorrhea. TRH, emitted by the hypothalamus, not just animates arrival of TSH by the pituitary yet in addition invigorates prolactin discharge. People with essential hypothyroidism have an uplifted prolactin reaction to TRH, bringing about more noteworthy prolactin emission in light of TRH incitement; hence hyperprolactinemia and secondary amenorrhea can be an outcome of essential hypothyroidism. Essential hypothyroidism may likewise prompt huge extension of the pituitary organ due to thyrotroph hyperplasia and likely lactotroph hyperplasia, however treating the hypothyroidism should bring about relapse of the hyperplasia and standardization of the prolactin level (Fourman & Fazeli, 2015). This can be ruled out due to her hypothyroidism being controlled by her Levothyroxine and TSH levels being normal.
Management Plan
Since KM has the desire to get pregnant but has not had regular periods and sometimes goes months without a period, she was placed on Provera 10mg daily for 5 days. Medroxyprogesterone (Provera) is a kind of female hormone (progestin). This medicine is like the progesterone that your body normally makes and is given to supplant the hormone when your body isn’t making enough of it. This prescription has a few uses. One such use is in ladies who are not pregnant and not experiencing menopause. this medicine is utilized to treat unusual bleeding from the uterus and to reestablish typical menstrual periods in ladies who have quit having them for several months (amenorrhea). It works by stopping the growth of the lining of the uterus and by causing the uterus to produce certain hormones. Once the cycle of pills is complete, the body with go through a “withdraw” from the hormone and a menstrual cycle will begin (MedlinePlus, 2019). NURS 6025 Week 9 Essay Assignment
Along with this medication, the patient was instructed to use a Basal Body Temperature Graph. This graph is used by anyone who is trying to conceive and tracts their BBT to find out when they are ovulating or if they are ovulating at all. A woman’s body temperature drops a bit just before the ovary releases an egg then, 24 hours after the egg’s release, the body’s temperature rises and stays up for several days (Cigna International, 2017). She will need to consistently obtain her resting temperature every morning before getting out of bed. The schedule will ensure that the temperature is the most accurate. This should help her to keep track of her ovulation cycle and her likelihood of intercourse at the correct time will increase her chances of pregnancy occurring.
She should begin prenatal vitamins in the event that she gets pregnant, she will have the correct supplementation to help with the pregnancy during the most critical time after conception. She will need to follow up with us in one month to assess the effectiveness of the Provera and should she need another cycle of medication it can be prescribed. NURS 6025 Week 9 Essay Assignment