Abdominal Pain And Irregular Menstrual Cycles Assignment

OBGYN SOAP Note

SUBJECTIVE DATA

CHIEF CONCERN: Abdominal pain and irregular menstrual cycles

HPI: Chief Complaint: Abdominal pain and irregular menstrual cycles

HPI (History of Present Illness):

D.P., a 34-year-old female, presents to the clinic with a chief complaint of abdominal pain and irregular menstrual cycles. She reports experiencing intermittent lower abdominal discomfort for the past three months. The pain is dull, with occasional sharp, cramp-like episodes. The intensity of the pain varies but is usually mild to moderate. D.P. also notices that her menstrual cycles have become irregular, occurring every 35-45 days instead of her usual 28-day cycle. Abdominal Pain And Irregular Menstrual Cycles Assignment

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PMH: D.P. has a history of polycystic ovary syndrome (PCOS), which was diagnosed two years ago. She has been managing her condition with lifestyle modifications and has not required specific medications or surgical interventions. She has regular check-ups with her primary care physician and gynecologist for monitoring and guidance.

SH: D.P. is married and works as a marketing executive in a corporate setting. She leads a sedentary lifestyle due to the nature of her job. She does not smoke, drink alcohol, or use recreational drugs. D.P. expresses concerns about her weight, reporting gradual weight gain over the past year.

CURRENT MEDICATIONS: Currently taking any medications.

ALLERGIES: No known allergies

FAMILY HISTORY: D.P. has a family history of type 2 diabetes on her father’s side. No other significant gynecological or reproductive disorders were reported in her immediate family. Abdominal Pain And Irregular Menstrual Cycles Assignment

FOCUSED ROS:

General: D.P. denies recent weight changes, fever, fatigue, or night sweats.

Skin: No rashes, itching, or skin changes were reported.

Cardiovascular: No chest pain, palpitations, or edema.

Respiratory: No shortness of breath, cough, or wheezing.

Gastrointestinal: D.P. reports intermittent abdominal pain but denies any changes in bowel habits, nausea, vomiting, or diarrhea.

Genitourinary: Apart from irregular menstrual cycles, no urinary complaints, dysuria, or hematuria were reported.

Neurological: No headaches, dizziness, or focal neurological symptoms.

Musculoskeletal: No joint pain, swelling, or limitations in mobility were reported.

Psychiatric: No symptoms of anxiety, depression, or mood changes were reported.

Endocrine: D.P. has a PCOS history and reports weight gain concerns.

Hematological: No history of bleeding disorders or abnormal bruising was reported. Abdominal Pain And Irregular Menstrual Cycles Assignment

OBJECTIVE DATA

PHYSICAL EXAM

Vital Signs: Heart Rate: 78 beats per minute, Respiratory Rate: 16 breaths per minute, Temperature: 98.6°F (37°C) Oxygen Saturation: 98% on room air

General: D.P. appears well-nourished and in no acute distress. She is conscious, alert, and cooperative.

Skin: No rashes, lesions, or abnormalities noted. Skin is warm and dry.

Cardio: Regular rate and rhythm, with no murmurs, gallops, or rubs detected. Peripheral pulses are equal and symmetrical—no edema in the extremities.

Resp:  Clear breath sounds bilateral. No wheezing, crackles, or decreased breath sounds.

Abdomen: soft and non-distended. No palpable masses or tenderness were noted upon light and deep palpation. No organomegaly is appreciated. Bowel sounds are present in all quadrants.

GU: External genitalia: No erythema, lesions, or discharge noted. No signs of trauma.

Vaginal examination: The vaginal walls are pink, moist, and without lesions: no abnormal discharge or foul odor was observed. The cervix appears normal without any visible abnormalities.

Neurologic: Cranial nerves are intact. No motor or sensory deficits were noted. Normal gait and coordination were observed. Abdominal Pain And Irregular Menstrual Cycles Assignment

Musculoskeletal: Full range of motion in all extremities. No joint swelling, tenderness, or deformities were detected.

Tests: ● Urinalysis ● Hormonal Assessment ● CBC ● Pelvic Ultrasound

DIAGNOSES

5 PLAUSIBLE DIFFERENTIAL DIAGNOSES WITH ICD CODES AND RULE IN /RULE OUT SUBJECTIVE AND OBJECTIVE SUPPORTING DATA

1. Polycystic Ovary Syndrome (PCOS) – E28.2

Reasoning: The patient has a known history of PCOS, characterized by irregular menstrual cycles, weight concerns, and a past diagnosis. The objective data include physical signs of polycystic ovaries on pelvic ultrasound, hormonal imbalances (elevated LH/FSH ratio), and subjective symptoms such as irregular cycles and weight gain. These findings strongly support PCOS as a plausible diagnosis.

2. Ovarian Cyst – N83.20

Reasoning: The patient’s abdominal pain, predominantly on the right side, along with the history of irregular menstrual cycles, suggests the possibility of an ovarian cyst. The pelvic ultrasound can help rule in or rule out the presence of an ovarian cyst by visualizing the ovaries. If an ovarian cyst is identified, it can explain the abdominal pain and irregular cycles. Abdominal Pain And Irregular Menstrual Cycles Assignment

3. Endometriosis – N80.9

Reasoning: Endometriosis can cause chronic pelvic pain and irregular menstrual cycles. Although not explicitly mentioned, the patient’s complaints of lower abdominal discomfort and dysmenorrhea could indicate endometriosis. A pelvic ultrasound may not definitively diagnose endometriosis, but it can help rule out other conditions and provide indirect support for considering this diagnosis.

4. Pelvic Inflammatory Disease (PID) – N73.9

Reasoning: Although the patient denies any urinary or vaginal symptoms, the lower abdominal pain and tenderness elicited during the physical examination raise the possibility of PID. In some cases, patients may not exhibit classic symptoms. Further testing, such as a cervical swab for sexually transmitted infections and inflammatory markers, may be required to rule in or rule out PID.

5. Hypothyroidism – E03.9

Reasoning: Hypothyroidism can lead to irregular menstrual cycles and weight gain, both of which the patient reports. The patient’s concerns about weight gain and a sedentary lifestyle may further support this diagnosis. A thyroid-stimulating hormone (TSH) test can be conducted to assess thyroid function and confirm or rule out hypothyroidism.

FINAL DIAGNOSIS WITH ICD CODE

Polycystic Ovary Syndrome (PCOS) – ICD-10 code E28.2. Abdominal Pain And Irregular Menstrual Cycles Assignment

Polycystic Ovary Syndrome (PCOS) is a hormonal disorder that affects women of reproductive age. It is characterized by three main features: irregular menstrual cycles, excess androgen levels (male hormones), and the presence of multiple small cysts on the ovaries (Sadeghi et al., 2022). The patient’s history of irregular menstrual cycles and the physical exam findings of abdominal pain and tenderness align with the typical presentation of PCOS. Additionally, the patient has a known previous diagnosis of PCOS, further supporting this conclusion. PCOS is believed to be caused by genetic and environmental factors. Hormonal imbalances disrupt the normal menstrual cycle, leading to irregular periods. Increased androgen levels can cause acne, hirsutism (excessive hair growth), and weight gain (Sadeghi et al., 2022). The presence of multiple small cysts on the ovaries, visible on pelvic ultrasound, is a common finding in PCOS. Patients with PCOS may also experience other associated conditions, such as insulin resistance, obesity, type 2 diabetes, and cardiovascular disease. Therefore, individuals with PCOS need to undergo regular monitoring and adopt lifestyle modifications, including maintaining a healthy weight, exercising regularly, and managing insulin resistance if present. Abdominal Pain And Irregular Menstrual Cycles Assignment

TREATMENT PLAN

NON-PHARMACOLOGICAL:

1. Lifestyle Modifications: Provide education and support to the patient regarding the following lifestyle changes:

– Weight Management: Encourage a balanced diet and regular physical activity to achieve and maintain a healthy weight. Even as little as 5-10% weight loss can improve PCOS symptoms and hormone levels.

– Exercise: Recommend engaging in regular physical activity, such as aerobic exercises and strength training, for at least 150 minutes per week.

– Diet: Advise the patient to follow a balanced, low glycemic index (GI) diet focusing on whole grains, fruits, vegetables, lean proteins, and healthy fats. Limit the intake of processed foods, sugary drinks, and refined carbohydrates. Abdominal Pain And Irregular Menstrual Cycles Assignment

PATIENT EDUCATION:

1. Menstrual Cycle Monitoring: Educate the patient on tracking menstrual cycles, noting cycle length, duration, and any changes in symptoms. This will help monitor improvements or identify abnormalities that may require medical intervention (Islam et al., 2022).
2. Fertility Awareness: Discuss family planning options and provide information about potential fertility issues associated with PCOS. Explain the potential challenges and available fertility treatment options if pregnancy is desired.

Pharmacological

1. Oral Contraceptives: Prescribe a combination of oral contraceptives containing estrogen and progestin to regulate menstrual cycles, reduce androgen levels, and improve symptoms such as acne and hirsutism. These medications also provide contraception (Kumarendran et al., 2021). Abdominal Pain And Irregular Menstrual Cycles Assignment

FOLLOW UP:

Follow-up in two weeks to assess the patient’s progress, evaluate treatment effectiveness, and address any concerns or questions.

REFERRAL:

No referral is needed at this time.

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REFERENCES

Islam, H., Masud, J., Islam, Y. N., & Haque, F. K. M. (2022). An update on polycystic ovary syndrome: A review of current knowledge in the diagnosis, genetic etiology, and emerging treatment options. Women’s Health, 18, 17455057221117966.

Kumarendran, B., O’Reilly, M. W., Subramanian, A., Šumilo, D., Toulis, K., Gokhale, K. M., … & Nirantharakumar, K. (2021). Polycystic ovary syndrome, combined oral contraceptives, and the risk of dysglycemia: a population-based cohort study with a nested pharmacoepidemiological case-control study. Diabetes care, 44(12), 2758–2766. Abdominal Pain And Irregular Menstrual Cycles Assignment

Sadeghi, H. M., Adeli, I., Calina, D., Docea, A. O., Mousavi, T., Daniali, M., … & Abdollahi, M. (2022). Polycystic ovary syndrome: A comprehensive review of pathogenesis, management, and drug repurposing. International journal of molecular sciences, Abdominal Pain And Irregular Menstrual Cycles Assignment

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