Instructions
Response posts must demonstrate topic knowledge and scholarly engagement with peers. This is not the only criteria utilized for evaluation; substantive content is imperative. Substantive means that you add something new to the discussion supported with citation(s) and reference(s), you are not just agreeing. This is also a time to ask questions or offer information surrounding the topic addressed by your peers. Personal experience is appropriate for a substantive discussion, however should be correlated to the literature.
Please respond to at least 2 of your peer’s posts. To ensure that your responses are substantive, use at least two of these prompts:
- Do you agree with your peers’ assessment?
- Take an opposing view to a peer and present a logical argument supporting an alternate opinion.
- Share your thoughts on how you support their opinion and explain why.
- Present new references that support your opinions.
PEER 1: Nathan
Construct the subjective and objective data in a SOAP Note format.
Subjective
CC: 6-month history of fatigue
Subjective
HPI: Patient is a 38-year-old white female who presents to the clinic complaining of a 6-month history of fatigue. She denies any other symptoms, recent illness or change to her physical or emotion health. She denies feeling depressed or significant stressors that can cause her fatigue.
PMH:
General: HTN
OB History: Patient had three term births and one first-trimester spontaneous abortion (G4P3014). Patient had a tubal sterilization when she delivered her third child via cesarean section. Negative for pap tests or screens for STI.
Allergies: NKA
Medications: HCTZ 25mg po daily and Multivitamin 1tab po daily.
Social History: Patient is sexually active. She is in a monogamous relationship with her husband.
Family History: Negative for breast, ovarian, colon or uterine/endometrial cancers.
ROS:
Genito reproductive: Menstrual periods are regular with bleeding lasting 7-9 days. Patient uses super-absorbent tampons, changing approximately every two hours in the first couple of days of period. She relies on pads when she has a heavier flow. Patient reports she sometimes notices quarter-sized clots. It has been the case since the start of her period.
Patient denies intermenstrual or postcoital bleed.
Objective
PE:
VS: BP 138/87 P 78 T: 98.9F Ht 66 inches Wt 267 lbs BMI 43.09kg/m2
General: Patient is a well-developed obese white female in NAD.
Genitalia: No vulvar or vaginal lesions. There is a small dark blood present in the vault. No CMT or cervical lesions. Uterus and adnexal structures are difficult to palpate due to abdominal girth. However, uterus does not appear enlarged. No pelvic masses palpated.
CBC with platelets: Hemoglobin 10.1 g/dL, Hematocrit 29.8, WBC: WNL, TSH:1.8 (WNL). RBC indices are consistent with iron deficiency.
What is your assessment of this patient?
Aside from obesity and iron deficiency, my assessment of this patient is abnormal uterine bleed, possibly of endometrial causes (AUB-E). The prevalence of AUB among non-pregnant women of reproductive age is up to 35 percent globally (McGregor et al., 2022). It is the bleeding condition that is abnormal in regularity, volume, frequency, and duration in the absence of pregnancy, and has occurred for at least six months (Alexander et al., 2017). Meanwhile, an AUB-E is a form of AUB when the patient’s ovaries produce predictable and cyclic menstrual patterns despite experiencing excessive bleeding (Alexander et al., 2017). There is a likelihood of endometrial issues. An average blood loss during the menstruation cycle is from 5ml to 80 ml (Alexander et al., 2017). Patient reports needing to change her super-absorbent tampons approximately every two hours and will still need to have pads as backup when she has a heavier flow. She was also seeing quarter-sized blood clots. This seems excessive. Unfortunately, she has always had this throughout her reproductive life. As a result, she never consulted a provider, assuming it was normal. AUB is known to affect the woman’s quality of life. However, the patient seems to have normalized her condition because she has had symptoms as early as the onset of her period. She has learned to adjust to it without realizing that it is an unusual occurrence.
Alexander et al. (2017) suggested that if a patient presents with AUB from menarche, a coagulation disorder should be suspected. However, this patient has had a couple of vaginal deliveries and one cesarean section. Wouldn’t any coagulation disorders have manifested or been identified by now, if she truly has one? I will still order tests to rule out any coagulation disorders such as the von Willebrand disease, however.
What are your thoughts on the treatment plan of this patient?
Prior to deciding on a treatment, I will order tests to confirm the diagnosis. It is important to rule out pregnancy as a possible cause despite having tubal ligation or denying sexual activity (Alexander et al., 2017). A pregnancy test is still necessary. This patient is negative for STI. Her pap test is normal. Hypothyroidism as a cause of AUB is ruled out because of her normal TSH level.
I will order a transvaginal ultrasound. I will request the patient to schedule it between four and six days of her menstrual cycle. This will help in evaluating her endometrial echo-complex thickness for possible tissue sampling.
I will also recommend weight loss with a healthy diet and regular exercise. Her obesity is a contributing factor to her elevated blood pressure. Obesity is also one of the risk factors of AUB. Women with AUB are likely to be younger, white and obese (Alexander et al., 2017).
As for the treatment, there is a variety of options available to the patient. However, each option has its potential side effects and contraindications. There are surgical and non-surgical means. Uterine artery embolization and endometrial ablation are effective options for AUB (Alexander et al., 2017). It will be good to refer her to an OB-GYNE specialist. More importantly, it will be necessary to ask the patient regarding her preferred treatment for better compliance.
Is there any other information that you would obtain to assist you in determining treatment options?
Alexander et al. (2017) recommended a monophasic oral contraceptive to be taken twice a day to control the bleed, and supplementing dietary intake of iron if patient has a mild case of anemia. However, I am concerned that the birth control pill may be contraindicated because of HTN. Also, I will have to ask her if she has a history of other blood clots like a deep vein thrombosis. Hormonal contraceptives are known to cause blood clots (LeVasseur et al., 2022).
A seemingly safe option is NSAID therapy. NSAIDs are believed to reduce menstrual bleeding (Alexander et al., 2017). I can order Naproxen 550mg po on the first day of menses and then 275mg po daily until the menstrual bleeding stops. I will encourage the patient to increase iron-rich food items such as legumes, spinach and red meat to help her iron deficiency.
Which guidelines would you consult?
The American College of Obstetricians and Gynecologists has a recommended guideline when treating patients with AUB. Medical management is the first line of treatment while surgical management is recommended for those that are clinically unstable, not suitable for medical management or have failed to respond to medical management. They propose using medications such as hormonal birth control pills, hormone therapy, tranexamic acid, and NSAIDs (American College of Obstetrics and Gynecology, 2021)
References
Alexander, I.M., Johnson-Mallard, V., Kostas-Polston, E.A., Fogal, C.I., & Woods, N.F. (2017). Women’s health care in
advanced practice nursing.(2nd. ed.), New York, NY: Springer Publishing Company. ISBN: 978-0-8261-9001-7
American College of Obstetrics and Gynecology (2021). Abnormal uterine bleeding. https://www.acog.org/womens-
health/faqs/abnormal-uterine-bleeding
LaVasseur, C., Neukam, S., Kartika, T., Bethany, S. B., Shatzel, J., & DeLoughery, T. G. (2022). Hormonal therapies and
venous thrombosis: Considerations for prevention and management. Research and Practice in Thrombosis and
Haemostasis, 6(6). https://doi.org/10.1002/rth2.12763
MacGregor, R., Jain, V., Hillman, S., & Lumsden, M. A. (2022). Investigating abnormal uterine bleeding in reproductive
aged women. BMJ : British Medical Journal (Online), 378. https://doi.org/10.1136/bmj-2022-070906
PEER 2 : Rita
- With the above information, construct the subjective and objective data in a SOAP Note format.
Subjective (S):
CC: Fatigue
HPI:
Jessica, a 38-year-old white female presents for an office visit complaining of a 6-month history of fatigue. She reports no other symptoms, no recent illness or change to her physical or emotional health, including no depression or significant stress that might account for her fatigue. Reports that periods have been regular with bleeding lasting 7 to 9 days. Bleeding is very heavy, needing to use super-absorbent tampons, changing them approximately every two hours in the first couple of days of her period. She also relies on pads for backup during her days of heavier flow. She has noticed that she sometimes passes quarter-sized clots. Denies intermenstrual or postcoital bleeding.
PMH: Hypertension
PSH: C-section and tubal sterilization
Gynecological history:
G4P3013
No hx of abnormal paps
Periods-normal and regular, with bleeding lasting 7 to 9 days.
Allergies: No known drug allergies
Medications: Hydrochlorothiazide-25 mg PO qday, multivitamin
Social history:
Sexually active with only her husband.
Married with 3 children.
Sexual health: monogamous with male partner
Tobacco/nicotine: never
Alcohol: socially
Family history:
There is no family history of breast, ovarian, colon, or uterine/endometrial cancer
Review of Symptoms:
General: Patient denies fever, chills, fatigue, malaise or changes in weight.
Reproductive health: heavy bleeding while menstruating
Psychologic: Denies change to her physical or emotional health, including no depression or significant stress
Objective (O):
Gen: Patient is a well-developed obese 38 year old female who appears to be in no apparent distress.
VS:
T: 98.9
BP: 138/87
HR: 78
WT: 267 lbs
HT: 66”
BMI: 43.09
GI/GU: No vulvar or vaginal lesions; a small amount of dark blood is present in the vault. There is no cervical motion tenderness or cervical lesions. Her uterus and adnexal structures are difficult to palpate because of her abdominal girth, though the uterus does not appear to be enlarged and there are no pelvic masses palpated.
- What is your assessment of this patient?
Assessment (A):
Fatigue- R53.83
Iron deficiency anemia- D50.9
Abnormal uterine bleeding-N93.9
Morbid obesity-E66.01
Abnormal uterine bleeding causing fatigue due to heavy menstrual bleeding resulting in iron deficiency anemia based on lab results hgb of 10.1, hematocrit of 29.8
Plan (P):
Diagnostics/Labs: CBC with platelets reveal hgb level of 10.2, hematocrit 29.8 indicate iron deficiency . WBCs and platelets are within normal ranges. Thyroid-stimulating hormone level, which, at 1.8 mIU/L, is within normal limits.
Pap test and endometrial biopsy to rule out cancer and ultrasound.
3.What are your thoughts on the treatment plan of this patient?
Therapeutic: I would discuss starting an iron supplement with this patient and vitamin c to increase absorption due to her iron deficiency anemia, options to either start birth control pills, intrauterine contraception, or hormone therapy to help make periods more regular and reduce the amount of bleeding (Centers of Disease Control and Prevention, 2022). There are also surgical options such as dilation and curettage, operative hysteroscopy, endometrial ablation or resection and hysterectomy to decrease or stop bleeding but less invasive treatment options should be explored first. Options should be explored for shared decision making after collaboratively helping the patient reach evidence-informed and value-congruent medical decisions that she feels that will benefit her the most.
Educational: Iron should be taken with vitamin C to increase absorption. Schedule tests and follow up to review results.
Consultation/Collaboration: Follow up to review results of testings
4.Is there any other information that you would obtain to assist you in determining treatment options?
Questions I would ask would be how old the patient was when she got her first period, how long is her menstrual cycle, history of her menstrual cycle or concerns, family history of heavy menstrual bleeding and treatment, any accompanying symptoms such as pelvic pain or pressure, and how her periods affect her quality of life. Other questions before deciding on the best treatment for her would be if she plans on having more kids, if she has a history of migraine headaches with aura before starting birth control options, and what her thoughts are on the options explained to her.
5.Which guidelines would you consult?
Chronic heavy menstrual bleeding (HMB) is defined as abnormal uterine bleeding (AUB) that has occured for 6 months (Alexander, Johnson-Mallard, Kostas-Polston, Fogal & Woods, 2017). HMB can cause physical health problems such as iron deficiency anemia (IDA) and fatigue such as this patient (Kocaoz, Cirpan & Degirmencioglu, 2019). Treating the symptoms such as AUB and IDA would reduce the incidence of fatigue which is her priority complaint.
According to American College of Obstetricians and Gynecologists (ACOG) (2020), choice of treatment for AUB depends on clinical stability, overall acuity, suspected etiology of the bleeding, desire for future fertility, and underlying medical problems. The two main objectives of managing AUB are to control the bleeding and reduce bleeding in subsequent cycles. Hormonal management is considered the first line of therapy for patients with AUB.
References
Alexander, I.M., Johnson-Mallard, V., Kostas-Polston, E.A., Fogal, C.I., & Woods, N.F. (2017). Women’s health care in advanced practice nursing.(2nd. ed.), New York, NY: Springer Publishing Company. ISBN: 978-0-8261-9001-7
American College of Obstetricians and Gynecologists. (2020). Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/04/management-of-acute-abnormal-uterine-bleeding-in-nonpregnant-reproductive-aged-women
Centers for Disease Control and Prevention. (2022). Heavy Menstrual Bleeding. https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.htmlLinks to an external site.
Kocaoz, S., Cirpan, R. & Degirmencioglu, A. (2019). The prevalence and impacts heavy menstrual bleeding on anemia, fatigue and quality of life in women of reproductive age. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500811/
For the writer to know, if it helps, this is what I posted, there is no need to respond to this:
1. Subjective and Objective Data
Subjective
CC: “fatigue”
38-year-old Caucasian female. G4T3PA1L3. LMP: N/A. Hx. of fatigue over the past six months. Her periods are regular but prolonged, lasting about 7 to 9 days. She reports no intermenstrual or post-coital bleeding and is sexually active with only her husband. Denies recent illness change to her physical or emotional health, including no depression or significant stress that might account for her fatigue and denies other symptoms.
PMH: Hypertension. SURGICAL: C-section and tubal ligation on third child.
Allergies: NKDA
Medications: Hydrochlorothiazide 25 mg QD, daily multivitamin.
Social History: no tobacco. Drinks alcohol socially.
Family History: No breast, ovarian, colon, or uterine/endometrial cancers.
Health Maintenance: No history of abnormal Pap tests. Last PAP: N/A
Past GYN History: Regular menstrual periods, they last 7 to 9 days, uses super-absorbent tampons, changes every two hours in the first couple of days of her period. Relies on pads for backup during her days of heavier flow. Sometimes passes quarter-sized clots. No intermenstrual or postcoital bleeding and is sexually active with only her husband. No positive screens for sexually transmitted infections.
ROS: N/A
Objective
General: Well-developed, obese white female in no apparent distress.
VS- BP: 138/87, HR: 78 x’, Temp. : 98.9°F, HT : 5’6”. Wt: 267 Lbs. BMI:43.09 kg/m2.
GU: Pelvic Exam: no vulvar or vaginal lesions; a small amount of dark blood is present in the vault. There is no cervical motion tenderness or cervical lesions. Her uterus and adnexal structures are difficult to palpate because of her abdominal girth, though the uterus does not appear to be enlarged and there are no pelvic masses palpated.
Results from complete blood count present significant results in terms of hemoglobin and hematocrit. Hemoglobin levels were 10.1 g/dL, indicating low hemoglobin levels, as were hematocrit levels of 38, indicating low hematocrit levels. Other Red-blood indices are consistent with iron deficiency. Levels of Thyroid Stimulating hormone are 1.8 mIU/L and therefore within normal range.
2. Patient Assessment
Assessment of the diagnostic test results indicates that the patient has a diagnosis of Menorrhagia. This assertion is evidenced by prolonged periods lasting more than a week. She is obese, which predisposes her to hormonal imbalance hence the development of abnormal uterine bleeding. Excessive bleeding has led to anemia, evidenced by low hemoglobin and hematocrit levels.
3. Treatment Plan
Diagnostics: PT/INR/ aPTT, and fibrinogen. PAP smear, Endometrial biopsy, and Pelvic Ultrasound. (Mayo Clinic, 2022).
Therapeutic: The treatment plan encompasses medical management of the condition through hormone therapy. I would start with oral contraceptives, then try oral progesterone. If the patient does not want to take daily pills, I would recommend Tranexamic acid because it helps reduce menstrual blood loss and only needs to be taken at the time of the bleeding. After seeing the testing results, she could also be a candidate for Liletta (Mayo Clinic, 2022).
Hormone therapy can also be accomplished by administering Intravenous conjugated equine estrogen. The patient will also receive patient education on menstrual health.
Iron Supplements.
- Relevant Treatment Options and Guidelines
The option for treating abnormal uterine bleeding depends on the causative factor (Davis & Sparzak, 2022). I need more information from the ordered diagnostic testing to see if the cause is endometrial polyps, submucosal leiomyomas, or polycystic ovarian syndrome. Her hemoglobin is 10.1. According to the Clinical practice guidelines for treatment of dysfunctional uterine bleeding, her case is almost in the severe category of hemoglobin less than 10g/dL with active bleeding (Ford et al., 2020). According to Davis & Sparzak, medical intervention through hormonal therapy using Intravenous (IV) conjugated equine estrogen, combined oral contraceptive pills, and oral progestin is the most faceable option in managing abnormal uterine bleeding (2022).
Reference
Davis, E., Sparzak, P., B., (2022). Abnormal uterine bleeding. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532913/
Ford, R., Álvarez. D., Parra, A., Cauff, B., Iglesias, E., Llerena Pharm, V. (2020, May). Clinical practice guidelines for treatment of dysfunctional uterine bleeding. https://www.jdch.com/-/media/jdch/files/dysfunctional-uterine-bleeding-guideline.ashx?la=en&hash=3147AC6BA0FC0D97FABDDEB4F1E0D70D
Mayo Clinic. (2022, Jun 25). Menorrhagia (heavy menstrual bleeding). https://www.mayoclinic.org/diseases-conditions/menorrhagia/diagnosis-treatment/drc-20352834.
The Case Study we had to evaluate as our assignment was the following: (This is just for the writer to know, there is no need to evaluate this case study).
Jessica, a 38-year-old white female, has had three term births and one first-trimester spontaneous abortion (G4P3013). Her third child was delivered via cesarean section and she underwent tubal sterilization at that time.
She presents complaining of a 6-month history of fatigue. She reports no other symptoms, no recent illness or change to her physical or emotional health, including no depression or significant stress that might account for her fatigue. She does not smoke and uses alcohol only in social situations.
You order a complete blood count (CBC) with platelets, which reveals a hemoglobin level of 10.1 g/dL and hematocrit of 29.8; other RBC indices are consistent with iron deficiency. WBCs and platelets are within normal ranges. You also check her thyroid-stimulating hormone level, which, at 1.8 mIU/L, is within normal limits.
You inquired about her menstrual periods, she reports that they are regular, with bleeding lasting 7 to 9 days. She typically uses super-absorbent tampons, changing them approximately every two hours in the first couple of days of her period. She also relies on pads for backup during her days of heavier flow. She has noticed that she sometimes passes quarter-sized clots. While discussing these details, it becomes clear that Jessica has had heavy periods throughout her reproductive life, but she had never sought medical help because she had accepted her periods as a normal aspect of her life.
Jessica’s medical history is remarkable for hypertension and she currently takes 25 mg a day of hydrochlorothiazide. Her only other medication is a daily multivitamin. Her surgical history includes a tubal ligation. She reports no allergies.
She reports no intermenstrual or postcoital bleeding and is sexually active with only her husband. There is no family history of breast, ovarian, colon, or uterine/endometrial cancers and no history of abnormal Pap tests or positive screens for sexually transmitted infections.
On physical examination, Jessica is a well-developed, obese white female in no apparent distress. Blood pressure is 138/87, pulse 78, temperature 98.9°F, height 5’6”; weight 267 pounds, BMI 43.09 kg/m2. Aside from the obesity, there are no other relevant nonpelvic physical findings.
Her pelvic exam reveals no vulvar or vaginal lesions; a small amount of dark blood is present in the vault. There is no cervical motion tenderness or cervical lesions. Her uterus and adnexal structures are difficult to palpate because of her abdominal girth, though the uterus does not appear to be enlarged and there are no pelvic masses palpated.
Questions:
- With the above information, construct the subjective and objective data in a SOAP Note format.
- What is your assessment of this patient?
- What are your thoughts on the treatment plan of this patient?
- Is there any other information that you would obtain to assist you in determining treatment options?
- Which guidelines would you consult?
