Week 6 Response 2
Home>Homework Answsers>Nursing homework helpnursingMSNsee attachment16 days ago15.06.202510Report issuefiles (1)Week6Response2.pdfWeek6Response2.pdfSOAP NOTEDiagnos
tic Test Definition & How the Test WorksBest Suited
Conditions/
DiagnosesSpecial Considerations/
InstructionsPelvic
Ultrasou
nd –
Abdomi
nalNon-invasive imaging using sound
waves over the abdomen to
visualize pelvic organs.Large fibroids,
adnexal masses,
uterine
enlargementFull bladder required to
improve visualization.Pelvic
Ultrasou
nd –
Transva
ginalInsertion of a probe into the vagina
to produce detailed images of
uterus, ovaries, and adnexa.Fibroids, polyps,
endometrial
thickness, ovarian
cystsEmpty bladder preferred;
patient may experience
mild discomfort during
insertion.Saline
Infusion
Sonohys
terograp
hy (SIS)Saline is infused into the uterine
cavity during transvaginal
ultrasound to improve visualization
of the endometrium.Endometrial
polyps,
submucosal
fibroids,
intrauterine
adhesionsContraindicated in
pregnancy or active pelvic
infection. Done in
proliferative phase for
best visualization.Hysteros
copyThin, lighted scope inserted
through cervix into the uterus to
directly visualize the endometrial
cavity.Polyps,
submucosal
fibroids, abnormal
uterine bleedingMay be done in-office or
OR setting; pre-procedure
NSAIDs may help reduce
discomfort.Hysteros
alpingog
ram
(HSG)Contrast dye and X-ray used to
assess uterine shape and fallopian
tube patency.Infertility
evaluation, uterine
malformationsPerformed during early
follicular phase;
contraindicated in
pregnancy or infection.Laparos
copyMinimally invasive surgery using a
camera inserted into the abdomen
to directly visualize pelvic organs.Endometriosis,
chronic pelvic
pain, adnexal
massesRequires general
anesthesia; informed
consent for risks.Demographic Data
35-year-old African American female (HIPAA compliant)Subjective
Chief Complaint (CC): Pelvic pain and irregular vaginal bleedingEndomet
rial
Biopsy
(EMB)Tissue sample from endometrium
obtained using suction catheter to
evaluate histopathology.Abnormal uterine
bleeding,
endometrial
hyperplasia or
cancerAvoid during pregnancy;
may cause cramping or
spotting; schedule outside
of menses.Colposc
opyVisual inspection of cervix using a
colposcope following abnormal Pap
or HPV results; acetic acid
enhances visualization of abnormal
cells.Cervical dysplasia,
follow-up to
abnormal Pap/
HPVNot first-line for pelvic
pain; used only if
abnormal cervical
cytology is found.Endocer
vical
Curettag
e (ECC)Scraping of endocervical canal with
a curette to obtain tissue for
histologic analysis.Evaluation of
cervical dysplasia
or cancerOften done in conjunction
with colposcopy; may
cause cramping.Dilation
and
Curettag
e (D&C)Cervix is dilated and uterine lining
is scraped to obtain tissue or stop
bleeding.Heavy bleeding,
incomplete
miscarriage,
diagnosis of
endometrial
pathologyRequires sedation or
anesthesia; informed
consent essential; can be
diagnostic and
therapeutic.History of Present Illness (HPI):
35-year-old African American female presents with a 6-month history of intermittent pelvic pain
that is now constant and dull. She describes irregular spotting occurring between monthly
menses, which are otherwise regular. No associated fever, chills, nausea, weight changes, or
bowel or bladder symptoms.Additional HPI questions to ask:When did your last period start?How long is your typical cycle and flow?Any recent changes in pattern, severity, or associated symptoms?History of fibroids, endometriosis, or STIs?Past Medical History (PMH):
G2P2 via NSVD (ages 10 and 8). No chronic conditions, surgeries, or STIs. No allergies.
Medications: Daily multivitamin. Immunizations up to date. Last Pap smear was 2 years ago and
normal.Family History:
Mother: hypertension. No breast, uterine, or ovarian cancer in family.Social History:
Non-smoker. Social alcohol use. Sexually active with one male partner. Works full time. Diet
average, exercises occasionally. No IPV. Inconsistent contraceptive use.Review of Systems (ROS):• General: No weight change or fatigue
• GI: No constipation or bloating
• GU: Pelvic pain and irregular bleeding; no dysuria or hematuria
• GYN: No vaginal discharge
• Breasts: No lumps or nipple changes
• Preventive: Pap up to date; HPV vaccinated; no colonoscopy yetObjective
Vital Signs:Temp 98.6°F,BP 118/74,HR 78,RR 16,BMI 23.2Pelvic Exam Findings:• External genitalia normal
• Speculum: Small amount of blood in vault; cervix smooth, no lesions
• Bimanual: Uterus enlarged with palpable firm, irregular contour; no cervical motiontenderness (CMT); no adnexal masses or tendernessAssessmentDifferential Diagnoses:• Uterine fibroids (leiomyomas) – most likely due to enlarged, irregular uterus and
intermenstrual bleeding.• Endometrial polyp – possible cause of spotting, especially if intracavitary lesion present.
• Adenomyosis – less likely, as uterus typically diffusely enlarged and tender, which thispatient lacks.Presumptive Diagnosis: Uterine fibroids (leiomyomas)Confirmatory Diagnostic Test(s):• Transvaginal pelvic ultrasound – First-line to evaluate uterine size, fibroid location, and
structure• Saline infusion sonohysterography – If concern for intracavitary lesion or endometrial
pathology• CBC – To assess for anemia from blood lossPlanDiagnostic Plan:• Transvaginal ultrasound
• CBC
• Consider referral to GYN depending on findingsTreatment Plan:• Ibuprofen 600 mg PO q6h PRN for pain (NSAID)
• Combined oral contraceptives (COCs) to help regulate menses and reduce bleeding
• Ferrous sulfate 325 mg PO daily if anemia confirmedEducation:• Discussed fibroids: common, benign smooth muscle tumors of the uterus
• Reviewed risks and benefits of COCs (e.g., DVT risk, nausea, breast tenderness)
• NSAID education: take with food to minimize GI upset
• Nutritional support: increase iron-rich foods if anemic
• Potential for surgical management if symptoms worsen (e.g., myomectomy or hysterectomy)Follow-Up Plan:• Return in 4 weeks to review ultrasound results and labs
• Refer to GYN if large fibroids or unresponsive to medical managementPotential Complications if Untreated:• Progressive anemia
• Increased pelvic discomfort
• Possible impact on fertility or future pregnancy
• Fibroid growth requiring more invasive treatmentNational Guidelines Comparison:
According to the American College of Obstetricians and Gynecologists (ACOG), transvaginal
ultrasound is the first-line diagnostic tool for uterine fibroids. Initial management for
symptomatic fibroids can include NSAIDs and hormonal therapy. Surgical options are reserved
for refractory cases or patients desiring definitive treatment.Week6Response2.pdfSOAP NOTEDiagnos
tic Test Definition & How the Test WorksBest Suited
Conditions/
DiagnosesSpecial Considerations/
InstructionsPelvic
Ultrasou
nd –
Abdomi
nalNon-invasive imaging using sound
waves over the abdomen to
visualize pelvic organs.Large fibroids,
adnexal masses,
uterine
enlargementFull bladder required to
improve visualization.Pelvic
Ultrasou
nd –
Transva
ginalInsertion of a probe into the vagina
to produce detailed images of
uterus, ovaries, and adnexa.Fibroids, polyps,
endometrial
thickness, ovarian
cystsEmpty bladder preferred;
patient may experience
mild discomfort during
insertion.Saline
Infusion
Sonohys
terograp
hy (SIS)Saline is infused into the uterine
cavity during transvaginal
ultrasound to improve visualization
of the endometrium.Endometrial
polyps,
submucosal
fibroids,
intrauterine
adhesionsContraindicated in
pregnancy or active pelvic
infection. Done in
proliferative phase for
best visualization.Hysteros
copyThin, lighted scope inserted
through cervix into the uterus to
directly visualize the endometrial
cavity.Polyps,
submucosal
fibroids, abnormal
uterine bleedingMay be done in-office or
OR setting; pre-procedure
NSAIDs may help reduce
discomfort.Hysteros
alpingog
ram
(HSG)Contrast dye and X-ray used to
assess uterine shape and fallopian
tube patency.Infertility
evaluation, uterine
malformationsPerformed during early
follicular phase;
contraindicated in
pregnancy or infection.Laparos
copyMinimally invasive surgery using a
camera inserted into the abdomen
to directly visualize pelvic organs.Endometriosis,
chronic pelvic
pain, adnexal
massesRequires general
anesthesia; informed
consent for risks.Demographic Data
35-year-old African American female (HIPAA compliant)Subjective
Chief Complaint (CC): Pelvic pain and irregular vaginal bleedingEndomet
rial
Biopsy
(EMB)Tissue sample from endometrium
obtained using suction catheter to
evaluate histopathology.Abnormal uterine
bleeding,
endometrial
hyperplasia or
cancerAvoid during pregnancy;
may cause cramping or
spotting; schedule outside
of menses.Colposc
opyVisual inspection of cervix using a
colposcope following abnormal Pap
or HPV results; acetic acid
enhances visualization of abnormal
cells.Cervical dysplasia,
follow-up to
abnormal Pap/
HPVNot first-line for pelvic
pain; used only if
abnormal cervical
cytology is found.Endocer
vical
Curettag
e (ECC)Scraping of endocervical canal with
a curette to obtain tissue for
histologic analysis.Evaluation of
cervical dysplasia
or cancerOften done in conjunction
with colposcopy; may
cause cramping.Dilation
and
Curettag
e (D&C)Cervix is dilated and uterine lining
is scraped to obtain tissue or stop
bleeding.Heavy bleeding,
incomplete
miscarriage,
diagnosis of
endometrial
pathologyRequires sedation or
anesthesia; informed
consent essential; can be
diagnostic and
therapeutic.History of Present Illness (HPI):
35-year-old African American female presents with a 6-month history of intermittent pelvic pain
that is now constant and dull. She describes irregular spotting occurring between monthly
menses, which are otherwise regular. No associated fever, chills, nausea, weight changes, or
bowel or bladder symptoms.Additional HPI questions to ask:When did your last period start?How long is your typical cycle and flow?Any recent changes in pattern, severity, or associated symptoms?History of fibroids, endometriosis, or STIs?Past Medical History (PMH):
G2P2 via NSVD (ages 10 and 8). No chronic conditions, surgeries, or STIs. No allergies.
Medications: Daily multivitamin. Immunizations up to date. Last Pap smear was 2 years ago and
normal.Family History:
Mother: hypertension. No breast, uterine, or ovarian cancer in family.Social History:
Non-smoker. Social alcohol use. Sexually active with one male partner. Works full time. Diet
average, exercises occasionally. No IPV. Inconsistent contraceptive use.Review of Systems (ROS):• General: No weight change or fatigue
• GI: No constipation or bloating
• GU: Pelvic pain and irregular bleeding; no dysuria or hematuria
• GYN: No vaginal discharge
• Breasts: No lumps or nipple changes
• Preventive: Pap up to date; HPV vaccinated; no colonoscopy yetObjective
Vital Signs:Temp 98.6°F,BP 118/74,HR 78,RR 16,BMI 23.2Pelvic Exam Findings:• External genitalia normal
• Speculum: Small amount of blood in vault; cervix smooth, no lesions
• Bimanual: Uterus enlarged with palpable firm, irregular contour; no cervical motiontenderness (CMT); no adnexal masses or tendernessAssessmentDifferential Diagnoses:• Uterine fibroids (leiomyomas) – most likely due to enlarged, irregular uterus and
intermenstrual bleeding.• Endometrial polyp – possible cause of spotting, especially if intracavitary lesion present.
• Adenomyosis – less likely, as uterus typically diffusely enlarged and tender, which thispatient lacks.Presumptive Diagnosis: Uterine fibroids (leiomyomas)Confirmatory Diagnostic Test(s):• Transvaginal pelvic ultrasound – First-line to evaluate uterine size, fibroid location, and
structure• Saline infusion sonohysterography – If concern for intracavitary lesion or endometrial
pathology• CBC – To assess for anemia from blood lossPlanDiagnostic Plan:• Transvaginal ultrasound
• CBC
• Consider referral to GYN depending on findingsTreatment Plan:• Ibuprofen 600 mg PO q6h PRN for pain (NSAID)
• Combined oral contraceptives (COCs) to help regulate menses and reduce bleeding
• Ferrous sulfate 325 mg PO daily if anemia confirmedEducation:• Discussed fibroids: common, benign smooth muscle tumors of the uterus
• Reviewed risks and benefits of COCs (e.g., DVT risk, nausea, breast tenderness)
• NSAID education: take with food to minimize GI upset
• Nutritional support: increase iron-rich foods if anemic
• Potential for surgical management if symptoms worsen (e.g., myomectomy or hysterectomy)Follow-Up Plan:• Return in 4 weeks to review ultrasound results and labs
• Refer to GYN if large fibroids or unresponsive to medical managementPotential Complications if Untreated:• Progressive anemia
• Increased pelvic discomfort
• Possible impact on fertility or future pregnancy
• Fibroid growth requiring more invasive treatmentNational Guidelines Comparison:
According to the American College of Obstetricians and Gynecologists (ACOG), transvaginal
ultrasound is the first-line diagnostic tool for uterine fibroids. Initial management for
symptomatic fibroids can include NSAIDs and hormonal therapy. Surgical options are reserved
for refractory cases or patients desiring definitive treatment.Bids(47)Dr. Ellen RMMISS HILLARY A+Dr. Aylin JMDr. Sarah Blakefirstclass tutorsherry proffMUSYOKIONES A+Dr ClovergrA+de plusSheryl HoganPROF_ALISTERProWritingGuruDr. Everleigh_JKIsabella HarvardBrilliant GeekAshley EllieMath GuruuLarry Kellyabdul_rehman_miss AaliyahShow All Bidsother Questions(10)YOURlecturerAssignment 2:Animal ResearchQuestionnaire DesignFOR PROFESSOR RYAN ONLYUOP_MKT421_FINAL EXAM_LATEST_TUTORIAL_UPDATED_ON_25_MAY_2015PSY 340 week 4Finance (inst) for Accounting_QueenScotland Music AssignmentManagementhttp://www.google.ae/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0CDMQFjAC&url=http%3A%2F%2Fwww.homeworkmarket.com%2Fsites%2Fdefault%2Ffiles%2Fq5%2F04%2F05%2Fmgt300_casestudy_23-24.pdf&ei=sbhiVdujFsXW7Abv7oH4DQ&usg=AFQjCNEtOMoyWUQG8u2s320K
Needs help with similar assignment?
We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper
Get Answer Over WhatsApp
Order Paper Now
