Polycystic Ovarian Syndrome
Week 11 Soap Note: Polycystic Ovarian Syndrome
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
August 14, 2016
Patient Initials: FJ Age: 23 Gender: Female
SUBJECTIVE DATA:
Chief Complaint: “I have increased coarse body hair, irregular periods, and pelvic pain for the past one year”. Comment by Erica Gifford: Great CC
History of Present Illness: FJ is a 23-year-old G0P0 African American obese female who presented to the clinic with complaint of increased coarse body hair; irregular periods, and pelvic pain for the past one year. FJ reported that she noticed weight gain, especially around her waist; increased hair growth on her chest, chin, lips, stomach, back, thumbs, and toes; and oil skin, acne, and dandruff. Patient also reported that she used to have quite regular period, but for the past one year, she skips periods two to four months before her next menstrual cycle. Patient reported that she wants to get pregnant, but she has never been pregnant. Patient reported breast pain and lower abdominal/pelvic pain. She also reported that she got married last years, and she started monitoring her ovulation with an over the counter ovulation kit. She noticed that she does not ovulated for the past one year since she started checking. Patient reported that she has skin tags, such as excess skin on her armpits and neck area. She is sad because of the reported symptoms and not being able to conceive. She decided to see an obstetrics and gynecologist for an evaluation and treatment. Patient denied fever, chills, nausea, vomiting, diarrhea, or constipation.
Location: Pelvic, lower abdominal, uterus, skin, and breast.
Duration: One year
Quality: Pelvic/lower abdominal pain; breast pain; increased skin growth.
Radiation: None
Severity: 7/10 on pain scale
Timing/Onset: One year ago.
Alleviating Factors: Pain medication and heating pad.
Aggravating Factors: None
Relieving Factors: Ibuprofen pain medication and heating pad.
Treatments/Therapies: Over the counter ibuprofen pain medication, and heating pad.
Medications: Motrin 200-400 mg orally every 6 to 8 hours as needed for pain.
Allergy: No known drug or food allergy.
Past Medical History: None
Past Surgical History: None
GYN History: LMP 07/15/2016; last Pap smear 2/20/2015: negative; menarche 12; cycle: 5 days, but irregular; age of first intercourse 18 year; sexual active and heterosexual with only one sex partner; no birth control measures.
OB History: Gravida: 0 Para: 0
Personal/Social History: Married; college graduate; employed; lives at home with the husband; denied alcohol abuse, tobacco abuse or illicit drug abuse.
Immunizations: Flu vaccine 11/24/16; no pneumococcal shot.
Family History: Father: Diabetes, hyperlipidemia, BPH, hypertension; Mother: hypertension, diabetes. Siblings alive and well.
Review of Systems:
General: Positive weight gain; no fever, no night sweats, no chills, no fatigue, or no weakness.
Head: Admitted dandruff, denied dizziness, migraine or headache.
Eyes: Denied visual problem
Chest: no chest pain, cough, SOB
Heart: No palpitation, no irregular heartbeat
Breast: Admitted breast pain; no erythema, inflammation or nipple discharge.
Gastrointestinal: Reported lower abdominal pain; central obesity; increased waist fat; denied nausea/vomiting, constipation, or diarrhea.
Urinary: denied urinary tract infection or problems; no dysuria or urinary frequency.
GYN: Reports pelvic pain, irregular periods, difficult getting pregnant, no ovulation, skipped periods 2 to 4 months before her next menstrual cycle; no menorrhagia, no vaginal bleeding or discharge.
Musculoskeletal: denied pain radiation, muscle or joint pain.
Skin: reports acne, oily skin, increased coarse hair growth on chest, stomach, back, thumbs, and toes. Patient reported skin tags like excess skin on armpit and neck.
Psychiatry: No mental health problems; mood changes, depression or anxiety.
Neurological: denied dizziness, weakness, or seizures.
Endocrine: No thyroid problem, no diabetes, no hot/cold intolerance.
Immunologic: No recurrent infections or immune deficiencies.
Hematologic: No cancer, anemia, blood transfusion or bleeding disorder.
OBJECTIVE DATA
Physical Exam:
General: Patient is obese, pleasant, alert/oriented, and answers questions appropriately. No acute distress.
Vital signs: T 37.0, B/P 125/76, P 68; RR 16; SPO2 100% RA. Weight 182 pounds, BMI 30.3, Height 5ft 5in. Weight reflected 15 pounds increase from what the patient reported was the last weight last 4 months.
HEAD: Atraumatic, normocephalic; scalp: + dandruff.
Neck: supple, excess skin fold, no lymphadenopathy, no thyromegaly.
Chest/Lungs: Increased coarse chest hair noted; non-labored breathing; clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen/pelvic: lower abdomen/pelvic tenderness, enlarged multiple ovaries noted, obese, waist circumference >35; waist-to-hip ratio > 0.85; upper/lower abdominal hair.
Back: increased upper back hair noted, Normal curvature.
Skin: Increased coarse hair noted on the chin, lips, chest, upper/lower abdomen, upper back, thumbs, toes. Oily skin, acne, skin tags like excess skin on armpit/neck, and acanthosis nigricans noted on neck and armpits.
Breast: + pain/tenderness; no redness, swelling or discharge.
Genitals: External genital normal, except clitoris that is enlarged, vagina pink, and cervix closed; no rash, redness or discharge. Comment by Erica Gifford: What about uterus size any tenderness? Bimanual exam?
ASSESSMENT:
Lab Test and Results:
Pregnancy urine tests for human chorionic gonadotropin (hCG): negative, blood tests like testosterone/androgen test: high/abnormal; Prolactin test: level high/abnormal, + infertility; cholesterol/triglycerides blood test: abnormal; TSH test: normal rule out under/over active thyroid; hydroxyprogesterone: normal ruled out adrenal problem. Glucose tolerance/insulin levels: + insulin resistance. Luteinizing hormone concentration/follicle–stimulating level test: Elevated.
Vaginal ultrasound (sonogram): + multiple cysts in the ovaries; thicker endometrium lining.
Differential Diagnosis:
1. Polycystic Ovarian Syndrome
2. Cushing Syndrome
3. Premature Ovarian Failure
Polycystic Ovarian Syndrome (PCOS): Women’s Health (WH, 2014) described polycystic ovarian syndrome as an imbalance of woman’s sex hormones estrogen and progesterone, which causes development of ovarian cysts and irregular or absent menstrual cycle in women. Also, the hormonal imbalance leads to fertility, cardiac function, blood vessels, hormones, and appearance problems. According to WH (2014), Women with PCOS usually have elevated levels of male hormones (androgens); missed or irregular periods; multiple little ovarian cysts; hirsutism like increased hair growth on the face, chest, stomach, back, thumbs, or toes; acne, oily skin, or dandruff; weight gain or obesity, usually with extra weight around the waist; pelvic pain; anxiety or depression; and sleep apnea. Diagnosis of PCOS according to WH (2014) is based on acne and/or hirsutism; infertility due to anovulation; abdominal obesity; endocrine abnormalities based on laboratory tests; elevated androgen/testosterone level; positive insulin resistance; elevated luteinizing hormone concentration; follicle–stimulating level; multiple cysts in the ovaries; thicker endometrium
Polycystic ovarian syndrome is selected as the primary diagnosis because the patient’s clinical presentations; laboratory tests; and sonographic evaluations as aforementioned confirmed the diagnosis of polycystic ovarian syndrome. In fact, the results of the laboratory tests, radiologic evaluation; physical examination; and clinical presentation as aforementioned are all synonymous with the recommended clinical guideline for diagnosis of the PCOS. Comment by Erica Gifford: Excellent primary diagnosis
Cushing Syndrome (CS): The Pituitary Society (PS, 2015) described Cushing syndrome as the condition that occur due to excess cortisol hormone in the body. Cushing’s syndrome is fairly rare, but mostly found in women than men between ages 20 to 40. Signs and symptoms as described by PS (2015) are weight gain, hypertension, irritability, round face, fatigue, menstrual irregularity, poor concentration, poor short term memory, excess hair growth in women, red, ruddy face, and extra fat around the neck. Cushing’s syndrome is also usually associated with moon facies, central fat deposition, bruising easily, decreased libido, stretch marks, sleep disturbance, hypertension, muscle wasting, abdominal striae, buff alo hump, and osteoporosis. Cushing syndrome is ruled out as the primary diagnosis for the patient because the signs and symptoms of CS that are specific to CS alone, such as buff alo hump, stretch marks, easily bruise, decreased libido, moon face, and sleeping disturbance were not synonymous with the patient’s clinical presentation. Moreover, diagnosis of CS cannot be made based on symptoms alone; but with the use of laboratory tests that measures the amount of cortisol in the patient saliva or urine and the clinical presentation according to PS (2015).
Premature Ovarian Failure (POF): According to American Society for Reproductive Medicine (ASRM, 2015), POF is cessation of ovarian functioning before age 40 due to autoimmune disorder affecting the thyroid and adrenal glands; family history of POF; and medical treatments, such as chemotherapy and radiation therapy. Symptoms of POF according to ASRM (2015) are similar with menopause, such as irregular menstrual periods, hot flashes, night sweats, irritability, vaginal dryness, and trouble sleeping. Premature ovarian failure is ruled out as the primary diagnosis because the symptoms associate with the condition are not synonymous with most of the symptoms presented by the patient.
PLAN:
Laboratory /Diagnostic Tests and Results:
The initial laboratory test that was completed was urine human chorionic gonadotropin level test to rule out pregnancy: Result- negative. Other laboratory/diagnostic tests include:
Blood tests like testosterone/androgen test: high/abnormal confirming high male sex hormones and the physical presentations; Prolactin test: level high/abnormal, + infertility; luteinizing /follicle-stimulating hormone blood level test are high and abnormal in this patient while the patient is not pregnant; cholesterol/triglycerides blood test: abnormal; TSH test: normal ruled out under/over active thyroid; hydroxyprogesterone: normal ruled out adrenal problem. Glucose tolerance/insulin levels: + insulin resistance.
Vaginal ultrasound (sonogram): + multiple cysts in the ovaries; thicker endometrium lining.
Treatment / Management Plan and Follow up Care
Polycystic ovarian syndrome is selected as the primary diagnosis after physical, laboratory, and diagnostic tests ruled out other possible differential diagnosis, and treatment/management plan for the condition will depend on the patient‘s needs or goals because there is no cure for the condition according to WH (2015). Treatment/management therapy typically focus on either fertility improvement or treating the symptoms of hyperandrogenism (hirsutism) explained by WH (2015); however, long term measures should be taken to restore regular menses and prevent endometrial hyperplasia. The patient desire is to become pregnant. Therefore, the first line of treatment, and the safest measure to restore ovulation is weight loss since patient is obese. Patient will be placed on calorie restricted diets, such as limiting carbohydrates and fats; eat more proteins, fruits/vegetables, and regular exercise (Tharpe, Farley & Jordan, 2013).
Medications:
