Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

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Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

Respond to  your colleagues’ post below and explain how you might think differently about the types of tests you might recommend and explain why. Use your Learning Resources and/or evidence from the literature to support your position. APA FORMAT with 2 Scholarly References

 

 

COLLEAGUES POST

Episodic/Focused SOAP Note Template

 

Patient Information:

SS, 38-year-old, female Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

S.

CC (chief complaint): to discuss contraceptive options.

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HPI: SS is a 38-year-old Caucasian female with hx of G5 P5 LC6 that presents today to discuss contraception options. She states that she is not interested in having more children, but her new partner has never fathered a child. She denies other concerns or issues this visit.

Additional questions: How many pregnancies have you had? How many children do you have? Are any of them adopted? Have you ever had any miscarriages or abortions? Have you been on contraceptives before? If so, what type? Are you interested in an IUD or Subq form of birth control? How long have you known this partner? Have y’all had a conversation about family planning? Does he have any children? When was your last period?

Current Medications: Excedrin Migraine: last taken last month before menstrual cycle, and Vitamin C.

Allergies: no known allergies to food, medication, or environment

PMHx: Migraines with aura of vision changes to right eye; Exercise-induced asthma, IBS

Soc & Substance Hx: Her social history is negative for alcohol, tobacco, and recreational drugs. Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

Fam Hx: Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Susan has one older sister with no medical problems and one younger brother with no reported medical problems.

Surgical Hx: Her surgical history is remarkable only for tonsils as a child.

Mental Hx: Negative for mental health issues, diagnosis, or concerns

Violence Hx: No concerns for abuse, violence exposure or guns in the home.

Reproductive Hx: Menstrual history: [LMP: November 2023; cycles come every 28-32 days, for 5-8 days, and on her heaviest day she must use a super tampon every hour and get up to change her pad 2-3 times at night; pregnant (no), G5 P5 LC6, nursing/lactating (no), contraceptive use (none), types of intercourse (oral, anal, and vaginal), gender sexual preference (males), and any sexual concerns (none). Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. NECK: supple without adenopathy

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations.

RESPIRATORY: No shortness of breath, cough, or sputum.

BREASTS: No discharge or nipple changes.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: Denies bleeding, or bruising. Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

LYMPHATICS: No history of splenectomy.

PSYCHIATRIC: Reports feeling “okay”

ENDOCRINOLOGIC: Denies sweating or cold or heat intolerance. Denies polyuria or polydipsia.

GENITOURINARY/REPRODUCTIVE: No burning during urination. LMP: 11/01/2023. Denies breast-lumps, pain, discharge; Denies vaginal discharge, pain during sex; reports sexually active (oral, vaginal and anal)

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Height 5’ 7” Weight 148 lbs (BMI 23.1), BP 118/72 P 68

Physical Exam:

General: Well groomed, dressed appropriately for the weather

Head: NC/AT; EYES: sclera clear and white, PERRL at 3 mm; EARS: no drainage noted, TM pearly gray with landmarks noted; NOSE: nares clear and symmetric with no polyps noted; THROAT: neck supple without adenopathy; thyroid gland without nodules

Respiratory: lungs clear to auscultation bilaterally

Cardiovascular: S1, S2 heard clearly; no murmurs noted or edema

Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge

GI: soft, bowel sounds noted in 4 quadrants; no tenderness to touch; no splenomegaly.

VVBSU: no atrophy noted, except 1st-degree cystocele.

Cervix: firm, smooth, parous, without CMT

Uterus: RV, mobile, non-tender, approximately 10 cm

Adnexa: without masses or tenderness Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

NEXT STEPS AND CONSIDERATIONS:

  1. Diagnostic testing to check the endometrial lining regarding the heavy bleeding. Educate her on why we are doing this procedure, if she is comfortable with it, the results of the testing, and the next steps in the plan of care.
  2. Education on the different types and forms of contraception to see which one best matches her lifestyle. Teach her about the side effects of birth control, the efficacy of them and the steps to take when she wants to change the method or form.
  3. Conversing with her regarding her partner: Ask her why do she feel as though he is “the one”? How do she truly feel about him wanting more children and she don’t? Have they considered counseling to have a mediator to help them come up with a decision regarding family planning?
  4. The methods appropriate for Susan for contraception are the progestin only methods of contraception such as POPs, DMPA (Depo-Provera injection), implants and LNG IUDs related to her migraines with aura. Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

Diagnostic results:

Ultrasound of Pelvis: Patient reports very heavy bleeding during menstruation that requires frequents changes with super-sized tampons throughout the day and at night. The most common causes of heavy menstrual bleeding include fibroids and adenomyosis and irregular non-cyclic menstrual bleeding is commonly caused by ovulatory dysfunction such as in polycystic ovaries, endometrial polyp, or an IUD. A pelvic ultrasound is the initial and often only imaging modality needed in the imaging evaluation of abnormal uterine bleeding and can accurately identify the common causes of abnormal uterine bleeding in the reproductive age group (Hill & Shetty, 2023). Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

Labs: CBC, Serum Ferritin and Transferrin Levels: While the CBC is appropriate for detecting anemia and can hint at possible iron deficiency (especially if reticulocyte hemoglobin is low), it alone does not accurately reflect a woman’s iron stores and the presence or absence of ID. Adequacy of iron stores can be measured using simple laboratory parameters including serum ferritin and transferrin saturation (Moisidis-Tesch & Shulman, 2022).

A.

Primary: Encounter for other general counseling and advice on contraception (Z30.09)

Contraception counseling is vital to women of childbearing age even if they do not want to have any more children. The fact that they still can should be discussed. Patient presents for consultation on contraception methods. According to Sarma (2023), all clinicians who care for patients of reproductive potential should become comfortable discussing pregnancy intent, preconception risk assessment, and contraceptive counseling. Such conversations should not be restricted to primary care, gynecology, or even Women’s Heart Health programs, as many people of reproductive potential never present to such settings. All encounters with patients of reproductive potential present opportunities to help them realize their pregnancy goals and avoid unintended pregnancy. Preconception and contraceptive counseling have never been more important. Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

Differential Diagnoses

  1. Leiomyoma of uterus (Uterine Fibroids) (D25.9): Uterine fibroids are one of the most common benign tumors of the female genital area, which occurs in 20–40% of women during the reproductive period. Tough benign and frequently asymptomatic, UF is associated with significant morbidities, including menorrhagia and other menstrual abnormalities, anemia, pelvic pain, infertility, pregnancy complications, and occasional mortality (Adebamowo et al., 2023). Patient presents with extremely heavy menstrual cycles that requires super tampon changes every hour throughout the day and [ad changes every 2-3 hours throughout the night.
  2. Iron Deficiency Anemia (D50.9) Iron deficiency (ID), defined as low body iron with or without anemia, is the main cause of anemia in men and women of all ages. Reproductive-aged women are at particular risk for ID anemia—during pregnancy due to significant increased requirements for iron, and outside of pregnancy, due to heavy menstrual bleeding. Diagnosis of iron deficiency is usually straightforward and characterized by a low ferritin level (Moisidis-Tesch & Shulman, 2022).
  3. Female Genital Prolapse (N81.9): Prolapse is diagnosed and staged with physical examination based on the maximum descent of vaginal tissue (anterior, posterior or apex) on Valsalva manoeuvre. Symptoms commonly begin when the bulge reaches within 0.5 cm of the vaginal opening (McLeod & Lee, 2023). Patient presents with 1st degree cystocele discovered during pelvic exam. Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

 

Encounter for other general counseling and advice on contraception: Provie shared decision-making counseling: This approach, which is considered ideal for preference-sensitive decisions that are highly dependent on individual values and needs, is designed to assist patients in making the best decision for themselves. In this way, patient autonomy and the diversity of preferences for contraceptive method characteristics can be respected, while at the same time, patients are offered support in aligning their preferences with the available options (Dehlendorf, 2022). Will start patient on her preferred method of birth control and will follow up in 3 months to monitor for efficacy. Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

Uterine Fibroids: complete diagnostic ultrasound of uterus in house to check the endometrial lining and to check for uterine fibroids. After US in house this visit, US tech will inform NP of findings and will converse with patient to update plan of care. RTC after nect steps are discussed.

Iron Deficiency Anemia: Draw blood during this visit to check ferritin and transferrin levels. Low ferritin levels are indicative of ID with high ferritin levels being associated with either primary or secondary hemochromatosis. After lab values have resulted, will follow up with phone call for patient to determine if supplemental medication is needed. Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

Female Genital Prolapse (Pelvic Organ Prolapse) (POP): Conservative management may be started in the primary care setting and includes lifestyle modifications (e.g., avoiding constipation and heavy work), pelvic floor physiotherapy and pessary use. Pelvic floor muscle training (PFMT) appears to result in improvements in POP stage and POP-associated symptoms. Randomized trials have demonstrated the benefit of PFMT, particularly with individualized training and/or supervision. Pessaries are silicone devices in a variety of shapes and sizes, which support the pelvic organs. Approximately half of the women who use a pessary continue to do so in the intermediate term of one to two years. Pessaries must be removed and cleaned on a regular basis (Rogers & Fashokun, 2022). Will follow up with patient on therapy and pessary treatment within 3 months to monitor for efficacy.

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Reflection:

With this case study, I learned so much more about women’s health that I really didn’t know or understand. I believe that this SOAP note focuses well on the next step for the patient and will lead to a great outcome f followed through. I learned so much more about contraceptives as I am looking into my own research regarding them. Health promotion for this patient would be to continue yearly gyn exams and yearly blood tests to continue to have overall good health. I would promote healthy eating habits, exercise, and hydration. Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

Hi, I support the comprehensive approach used in this SOAP note, especially in addressing the patient’s concerns about their reproductive health and offering a thorough plan for additional research and care. In order to customize contraceptive recommendations, the healthcare provider thoroughly understands the patient’s background, family history, and medical history by probing into her past in an appropriate manner (Ouyang et al., 2019). It is true that examining the patient’s partner dynamics and family planning conversations is crucial because it supports an all-encompassing care strategy.

I agree that a diagnostic test, like a pelvic ultrasound, should be recommended to look into the heavy menstrual bleeding. Patient-centered care is in line with informing the patient of the reasoning behind the procedure and going over the outcomes (Ouyang et al., 2019). It is also admirable that there is a focus on contraceptive education. The recommendation of progestin-only techniques is appropriate given the patient’s history of aura-producing migraines, demonstrating a sophisticated awareness of potential contraindications. In addition, incorporating family planning and relationship dynamics counseling is consistent with a holistic approach to healthcare. Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

By considering the case, as a healthcare provider shows that you are dedicated to providing continuing care and promoting health. An attitude toward preventive care can be seen in the promotion of annual gynecological exams, blood tests, and lifestyle changes (Britton et al., 2020). Establishing a foundation for a cooperative and productive patient-provider relationship involves the provider trying to fully comprehend and address the patient’s concerns as described by Ouyang et al., 2019). All things considered, this SOAP note demonstrates a deliberate and patient-centered approach to reproductive health, guaranteeing a comprehensive plan for the patient’s welfare. Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay

 

References

Britton, L. E., Alspaugh, A., Greene, M. Z., & McLemore, M. R. (2020). CE: An Evidence-Based Update on Contraception. The American journal of nursing, 120(2), 22–33. https://doi.org/10.1097/01.NAJ.0000654304.29632.a7

Ouyang, M., Peng, K., Botfield, J. R., & McGeechan, K. (2019). Intrauterine contraceptive device training and outcomes for healthcare providers in developed countries: A systematic review. PloS one, 14(7), e0219746. Uterine Fibroid Diagnosis Using a Transvaginal Ultrasound Scan Essay