Nrnp 6552: Advanced Nurse Practice In Reproductive Health

Nrnp 6552advanced Nurse Practice In Reproductive Health Careepisodic

Develop a comprehensive episodic/focused SOAP note for a reproductive health patient, including detailed patient information, history, physical examination, diagnostic results, differential diagnoses, and a well-supported plan. Incorporate evidence-based practices, reflect on the case, and address health promotion and disease prevention tailored to the patient’s demographic and health background, supported by at least three peer-reviewed references in APA 7th edition format.

Paper For Above instruction

In this paper, I will develop a comprehensive episodic SOAP note for a patient presenting with reproductive health concerns, demonstrating a thorough understanding of advanced nursing practice principles, evidence-based guidelines, and patient-centered care strategies. The SOAP note encompasses detailed patient data, a thorough history, meticulous physical examination, appropriate diagnostic interpretations, differential diagnoses, and a cohesive plan while integrating health promotion and disease prevention considerations.

Patient Information and Chief Complaint

The patient is a 28-year-old Hispanic woman presenting with irregular menstrual cycles and occasional pelvic discomfort. Her chief complaint (CC) is summarized as, "Irregular periods and pelvic pain over the last few months." This concise statement captures her primary concerns without extraneous detail, setting the course for further assessment.

History of Present Illness (HPI)

The patient, a 28-year-old Hispanic female, reports experiencing irregular menstrual cycles that fluctuate between 25 to 45 days, with some months showing no menses, and others with prolonged bleeding lasting over a week. The pelvic pain is described as dull, intermittent, located centrally, and sometimes radiates to the lower back, especially before or during menses. She reports the discomfort as mild to moderate, rated 4/10 on the pain scale, worsening during her menses and sometimes lasting several days. She notes increased fatigue and occasional lower abdominal cramping. No history of fever or abnormal vaginal discharge. The patient mentions stress and recent weight fluctuations but denies recent weight loss or gain. She reports no nausea, vomiting, or bowel changes. She states her periods are unpredictable and sometimes heavy, leading her to use super-absorbent pads more frequently.

LOCATES Analysis

• Location: Pelvic region, specifically lower abdomen and pelvis
• Onset: Several months ago, with progressive irregularity
• Character: Dull, intermittent pain, cramping sensation
• Associated signs and symptoms: Fatigue, menorrhagia (heavy bleeding), lower back pain
• Timing: Pain associated with menses and fluctuates in frequency and intensity
• Exacerbating/Relieving factors: Worsens with menses; partial relief with NSAIDs
• Severity: 4/10 to 6/10 during episodes

The patient's symptoms suggest menstrual irregularities with pelvic discomfort, possibly indicative of underlying gynecologic pathology.

Current Medications, Allergies, Past Medical and Surgical History

She reports using combined oral contraceptives (OCPs) for contraception with a dosage of ethinylestradiol 35 mcg and levonorgestrel 0.15 mg daily for the past year, mainly for cycle regulation. She denies OTC medications or herbal supplements. Allergies include a penicillin allergy characterized by mild rash, no known food or environmental allergies. Her past medical history includes no major illnesses, blood transfusions, or surgeries. She received her last tetanus booster five years ago. No prior pelvic surgeries or hospitalizations reported.

Social and Substance History

The patient is a university student, employed part-time as a librarian, and resides in urban settings with her family. She is a non-smoker and reports social alcohol use approximately once a month. She denies tobacco, recreational drugs, or illicit substance use. She indicates a healthy lifestyle but admits to occasional high-stress levels due to academic pressure. She reports using seat belts regularly, has functioning smoke detectors, and lives in a safe environment. She also discusses her reproductive choices, indicating she is sexually active with one partner and uses OCPs consistently. She is not currently pregnant or breastfeeding.

Family and Reproductive History

Her mother has a history of thyroid disorder, and her maternal grandmother suffered from osteoporosis. Her sister experienced irregular periods but no other significant illnesses. No reported genetic or hereditary disorders. Menarche occurred at age 12; last menstrual period (LMP) was approximately 20 days ago. She is not pregnant, nor does she wish to conceive currently. She reports using condoms occasionally but has been primarily relying on OCPs. She reports no history of sexually transmitted infections or concerns about sexual activity.

Review of Systems (ROS)

General: No fever, weight loss, or fatigue noted.

HEENT: No visual disturbances, ear or throat complaints.

Cardiovascular: No chest pain or palpitations.

Respiratory: No cough or dyspnea.

Gastrointestinal: No nausea, vomiting, or bowel irregularities.

Genitourinary: Irregular menses, heavy periods, occasional pelvic discomfort.

Neurological: No dizziness, numbness, or weakness.

Musculoskeletal: No joint pains or muscular complaints.

Hematologic: No bleeding tendencies or anemia symptoms.

Psychiatric: Mild stress with episodes of anxiety; no depression or self-harm.

Endocrine: No reported heat or cold intolerance; weight fluctuations but no overt thyroid symptoms.

Reproductive: Regular menstrual history; no abnormal vaginal discharge or dysplasia.

Allergies: Penicillin allergy (rash); no other known allergies.

Physical Examination

Vital Signs: BP 118/76 mmHg, HR 76 bpm, RR 16/min, Temp 98.6°F, BMI 24.5 kg/m².

Head: Normocephalic, atraumatic.

HEENT: PERRLA, EOMI, no scleral icterus, or oral lesions.

Neck: Supple, no lymphadenopathy or thyromegaly.

Abdomen: Soft, non-tender, non-distended; no palpable masses or hepatosplenomegaly.

Pelvic Exam: External genitalia appearing normal; speculum exam shows no lesions or discharge; bimanual exam reveals mildly tender ovaries with no adnexal masses or cervical motion tenderness.

Diagnostic Results

Laboratory tests ordered include a pregnancy test (confirming non-pregnant status), serum FSH, LH, and estradiol levels to evaluate ovarian function, and a thyroid function panel due to family history. Transvaginal ultrasound reveals small ovarian cysts bilaterally, measuring approximately 2 cm each, consistent with functional cysts or polycystic ovary morphology. Pap smear is scheduled during the next visit. Bloodwork for hemoglobin, CBC, and metabolic profile is pending.

Differential Diagnoses

1. Polycystic Ovary Syndrome (PCOS): Given irregular menses, ovarian cysts, and possible hormonal imbalance, PCOS is the leading diagnosis supported by ultrasound findings and clinical presentation (Azziz et al., 2016).
2. Thyroid Dysfunction: Family history and weight fluctuations necessitate thyroid panel testing; hyper- or hypothyroidism could cause menstrual irregularities (Hueston & McDermott, 2020).
3. Ovarian Cyst or Other Gynecological Pathology: The bilateral small cysts are benign, but differential includes benign or malignant ovarian masses; further imaging may be required if symptoms worsen (Swift et al., 2021).

Plan and Reflection

The plan involves confirming diagnosis through hormonal assays and ultrasound assessment; counseling on lifestyle modification to manage weight and stress; initiating metformin if PCOS diagnosis is confirmed to improve insulin sensitivity; and scheduling follow-up to monitor symptom progression and ovarian cyst resolution. Patient education emphasizes the importance of routine gynecologic examinations, awareness of symptoms suggestive of serious pathology, and safe contraceptive practices. Reflections include consideration of the preceptor’s approach, recognizing the value of early diagnostic intervention, and integrating patient-specific factors such as her family history and lifestyle. I concur with the plan, emphasizing patient education for self-monitoring and understanding disease implications. The holistic approach aligns with evidence-based guidelines endorsing individualized management for reproductive irregularities, promoting health and preventing complications (Davidson et al., 2018). In future cases, I would advocate for more detailed psychosocial assessment addressing stress management and exploring reproductive intentions.

References

• Azziz, R., et al. (2016). The diagnosis of polycystic ovary syndrome: Clarifying the role of biomarker testing. Fertility and Sterility, 105(3), 623–632.
• Hueston, C., & McDermott, M. (2020). Thyroid disorders in women: Management strategies. Journal of Women's Health, 29(4), 522–530.
• Swift, S., et al. (2021). Ovarian cysts: Diagnosis and management. Obstetrics & Gynecology, 137(2), 319–330.
• American College of Obstetricians and Gynecologists. (2018). Practice Bulletin No. 194: Polycystic Ovary Syndrome. Obstetrics & Gynecology, 131(5), e157–e171.
• Dumesnil, D. J., et al. (2020). Management of ovarian cysts in reproductive health. Fertility and Sterility, 114(4), 683–694.
• Shaw, J. L., et al. (2019). Reproductive endocrinology and infertility review. The New England Journal of Medicine, 381(4), 370–382.
• Baldwin, K. W., & Lamb, M. G. (2017). Gynecological imaging in ovarian pathology. Radiographics, 37(3), 884–899.
• Harlow, S. D., & Gellman, M. D. (2019). Women's health and gynecologic care. Smith’s Textbook of Endocrinology, 13th Edition.
• National Institutes of Health. (2017). NIH consensus development conference on polycystic ovary syndrome. NIH Publication No. 17-2221.
• World Health Organization. (2020). Clinical management of reproductive health conditions. WHO Guidelines for Female Reproductive Health.