Learning Goal: I'm working on a health & medical discussion question and need an explanation and answer to help me learn. I need two respond to the below SOAP notes Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of diagnostic tests you would recommend and explain your reasoning. Use your Learning Resources and/or evidence from the literature to support your position. Case Study Discussion: Gynecologic Health Deanna Getz Walden University NRNP 6552: Advanced Nurse Practice in Reproductive Health Care Dr. Maurer September 21, 2022 Post-Partum Chronic Hypertension Health Episodic/Focused SOAP *Questions I would ask are in parenthesis* Patient Information: Initials-F.P.; Age-30; Sex-female; Race-Caucasian (I would ask patient name, age, & race) S. CC: blood pressure monitoring HPI: F.P, is a 30-year-old G1P1 who presents for a 6-week postpartum visit for blood pressure monitoring and control. She developed severe hypertension at 36 weeks gestation, was admitted for a 3-day admission and placed on Labetalol. (I would ask any symptoms then and now; anything make symptoms worse or better?). She returned for bp checks twice weekly and self-blood pressure checks at home twice daily post-partum. At 38 weeks Nifedipine was added for bp management. Her blood pressure remained stable on this drug regimen. A subsequent uneventful vaginal delivery at 39 weeks with no complications. Location: high blood pressure, CV Onset: 36 weeks gestation Character: (I would ask) Associated signs and symptoms: (I would ask) Timing: (I would ask) Exacerbating/relieving factors: (I would ask) Severity: (I would ask) Current Medications: Labetalol 200mg every 8 hours; Nifedipine for blood pressure control; Tylenol 500mg every 6 hours PRN headache. No homeopathic products. Motrin 800 mg for post-delivery discomfort & occasional headaches Allergies: No medication, food, and environmental allergies. (I would ask). PMHx: All immunizations and screenings up to date. Last tetanus 2000. (I would ask this question). No past major illnesses, and surgeries. Soc & Substance History: Patient is a nurse, enjoys running and spending time with her family which consists of husband and newborn. No vaping, tobacco, and alcohol use. She always uses a seatbelt and does not text while driving. Smoke detectors are present in the house. Fam Hx: Parents and one brother alive and well. Grandparents deceased- maternal mother-breast cancer, paternal father-MVA. (I would ask, especially genetic diseases) Surgical Hx: Tonsillectomy. (I would ask) Mental Hx: Denies anxiety or depression. Violence Hx: No concerns or issues about safety (I would ask personal, home, community, sexual—current and historical). Reproductive Hx: LMP December 15, 202; G1P1, breastfeeding, contraceptive-condoms, types of intercourse- vaginal, with one partner, no sexual concerns. ROS: GENERAL: No fever, chills, weakness, or fatigue. HEENT: Eyes: No headache, visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough, or sputum. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia. GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: 12/15/2021. No breast lumps, pain, or discharge. No reports of vaginal discharge, pain, or bleeding. Not currently sexually active. ALLERGIES: No history of asthma, hives, eczema, or rhinitis. O. VS- temp- 97; pulse-80; resp-22; bp-128/72; 23.7 weight=175; height=6’0; BMI=23.7 General: pleasant woman who presents with husband and newborn. HEENT: AAOX3, PEARL Cardiovascular: S1, S2, no murmurs Respiratory: All lung fields clear Neurological: all cranial nerves intact Psychiatric: well-kept adult female, happily playing with new baby Endocrine: no polydipsia or polyuria Genitourinary/Reproductive: no dysuria, frequency or hesitancy with urination, vaginal delivery at 39 weeks of a healthy baby Diagnostic results: Laboratory testing in all cases of postpartum hypertension should include a complete hematologic assessment to assess for anemia, thrombocytopenia, and signs of hemolysis. According to Ghuman, Rheiner & Tendler et alt (2019), women with a history of hypertension in pregnancy have higher levels of glucose, insulin, triglycerides, total cholesterol and LDL cholesterol in comparison to women with a normotensive pregnancy. Similar to any secondary hypertension evaluation process, a complete renal function testing with serum potassium, uric acid, and urinary protein levels should be assessed for possible underlying diagnoses of hyperaldosteronism and chronic kidney diseases (Ghuman, Rheiner & Tendler et alt. 2019). In patients with symptoms and signs suggestive of postpartum thyroiditis and hypertension, thyroid function testing including TSH, free T4, T3, TSH receptor antibodies, and thyroid peroxidase antibodies should be obtained (Ghuman, Rheiner & Tendler et alt. 2019). A. Differentials- Hypertensive disorders of pregnancy include preexisting and gestation hypertension, preeclampsia, and eclampsia. Both labetalol and nifedipine are effective for the control of persistent post-partum HTN. Labetalol achieved control significantly more often and had fewer side effects (Qi, Qin, Ren et alt. 2020). What is known about the clinical pharmacology in relation to drug disposition in breast milk is derived from few published reports in medical literature. All antihypertensive medications are excreted in breast milk in varying degrees. Target range for blood pressure is below 160/110mm Hg and treating below is a source of debate. The American College of Cardiology and the American Heart Association define stage 1 hypertension as 130-139/80-89mmHg and stage 2 >140/90mmHg (Chandrasekaran, Badell, & Jamieson, D. 2022). Just as blood pressure medication may need to be discontinued is blood pressures are <110/70 or the patient is symptomatic. Intravenous hydralazine, immediate release nifedipine and labetalol remain the drug of choice for sever hypertension. Chronic or pre-existing hypertension is discovered preconception or prior to 20 weeks gestation. Hypertension that persists beyond the puerperal period can be termed chronic if it persists 12 weeks beyond delivery (Chandrasekaran, Badell, M. & Jamieson 2022). Gestation hypertension is hypertension that appears de novo after 20 weeks gestation and normalizes after pregnancy within 42 days post-partum (Visser, Hermes, Koopmans et. alt. 2019). The American College of Obstetricians and Gynecologists (ACOG) recommends medical treatment of persistent postpartum hypertension, defined as systolic BP (SBP) ≥150 mmHg or diastolic BP (DBP) ≥100 mmHg, on two or more occasions 4–6 hours apart. Currently there is little consensus on the exact timing that BP should normalize after delivery in women with gestational hypertension or preeclampsia. Guidelines from both the United States and Europe define transient hypertension in pregnancy as BP that normalizes by 6 to 12 weeks postpartum Pregnancy is a state of chronic volume and sodium overload that contributes to increased cardiac output, edema, and BP elevation. While much of the accumulated sodium is rapidly lost during delivery, it may take up to 2 months for the salt and water homeostasis to return to antepartum levels.3 The pattern of physiologic return to the prepregnant state may be impaired when patients have underlying conditions such as preeclampsia, chronic hypertension, and kidney or heart disease (Chandrasekaran, Badell, M. & Jamieson 2022). Secondary hypertension which is caused by a medical condition. The management of postpartum hypertension is determined by the underlying etiology of the blood pressure elevation and in this case a breast-feeding mother. Drug therapy may not be required for some women during the post-partum period, especially is the blood pressure is 160mmHg and/or DBP >110 mmHg Education- low fat, low salt diet, minimal use of NSAIDS Social Detriments of health- (are you employed, do you have health insurance, are you able to get your medications filled, do you have adequate housing in a safe neighborhood?) References Chandrasekaran, S., Badell, M. & Jamieson, D. (2022). Management of chronic hypertension during pregnancy. Journal of the American Medical Association, 327(17), 1700-1701. https://doi://10.1001/jama.2022.3919 Ghuman, N., Rheiner, J., Tendler, B., White, W., Ghuman, N, Rheiner, J., Tendler, B., & White, W. (2019). Hypertension in the postpartum woman: clinical update for the hypertension specialist, 11(12), 726-733. https://doi:// 10.1111/j.1751-7176.2009.00186.x Qi, H. Qin, J., Ren, L., Li, L., Lan, L., Gan, S., Zhang, Y. (2020) Efficacy of low dose nicardipine for emergent treatment of severe postpartum hypertension in maternal intensive care units: An observational study. Pregnancy Hypertension, 21,43-49 https://doi://10.1016/j.preghy.2020.04.012 Sharma, K., Greenem N., & Kilpatrick, S. (2017). Oral labetalol compared to oral nifedipine for postpartum hypertension: A randomized controlled trial. Hypertension in Pregnancy, 36(1), 44-47. https://doi://10.1080/10641955.2016.1231317 Visser, V., Hermes, W., Koopmans, C., VanPampus, M., Mol, B. & DeGroot, C. (2018). High blood pressure six weeks postpartum after hypertensive pregnancy disorders at term is associated with chronic hypertension. Pregnancy Hypertension, 3(4), 242-247. https://doi://109582090 focused note on Uterine Fibroids by Fnu Gisele Injoh Patient Information: M. K., 35 years old, Female, African-American. S. CC (chief complaint): The patient complained of dysmenorrhea and worsening menorrhagia more frequently than usual. HPI: 35 years old M. K., an African-American female, presented to the clinic with complaints of very heavy and painful menstrual flow that happens twice a month, flowing for more than seven days. The patient explained that about six months ago, it started getting worse as she would have her period sometimes two times a month and would not stop after three days as originally. The patient explained that she usually would have pain just on the first day, but for the last six months, she has suffered pains and cramps each time she has had her flow. The patient reported that this new severe situation is negatively affecting her lifestyle as she gets tired when she is on her flow. Current Medications: Rosuvastatin 5mg daily for High cholesterol Pantopraxole 40 mg daily for GERD Ibuprofen 20mg - 2 to 3 tabs up to three times daily as needed. Tylenol pm - 500mg - 2 tabs at HS as needed for insomnia. Allergies: the patient has no known food allergies and no known medication allergies. PMHx: the patient was diagnosed with high cholesterol and GERD a year ago Soc & Substance Hx: patient live alone and works as a lab tech; the patient denies ever using drugs, never smoked, and is a social drinker. Fam Hx: father (deceased) - had type 2 diabetes mellitus and hypertension; mother has hypertension and arthritis. The patient has a brother and a sister with no medical conditions. Surgical Hx: no prior surgical history on file. Mental Hx: no history of anxiety and depression. Reproductive Hx: Menstrual history - LMP; 8/24/22, 9/10/22. Has never been pregnant. ROS: GENERAL: patient lost 6 pounds in the last month and denied fever, chills, or weakness. The patient reports fatigue more. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: patient denies rash or itching. CARDIOVASCULAR: The patient denies chest pain, pressure, or discomfort. No palpitations or edema. RESPIRATORY: The patient denies shortness of breath, cough, or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. NEUROLOGICAL: patient denies headache, dizziness, numbness, or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness. HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: patient denies sweating or cold or heats intolerance. No polyuria or polydipsia. GENITOURINARY/REPRODUCTIVE: denies burning on urination. Pregnancy. No breast lump was reported from the self-exam, denies vaginal discharge, the patient is sexually active, and reports having a boyfriend. ALLERGIES: No known allergies. O. Physical exam: Bp-134/84, p - 86, R - 18, T- 98.5, O - 98%, Wt - 186, bmi - 26.7, LMP - 9/10/22. General: the patient is in no acute distress, awake, and alert. Heent: Head: normocephalic and atraumatic HEENT: Patient negative for nasal discharges, congestion, and sore throat. Her pupils are equal, round, and reactive to light and accommodation. Cardio; no abnormal heartbeats noticed; regular S1 and S2 heard on auscultation. Respiration; Patient denies shortness of breath or coughing. Musculoskeletal: patient with a good range of motion in all four extremities. Denies any pain in muscles. GI: good bowel sounds in all four quads of the abdomen. Abdomen is distended and non tender. The patient reports the last bowel movement today. Genito urinary: patient reports heavy menstruation, running for longer than seven days with lots of cramps and spasms in her lower abdomen. The patient is also positive for frequent urination. On palpation, the patient is positive for pelvic pain and inflammation of the uterus. Lower abdominal pain that sometimes radiates to the back. Psych: Patient alert and oriented to person, place, time, and situation. Diagnostic results: Ultrasound and MRI of abdomen and pelvis. MRI usually confirms what the US shows. MRI shows the fibroids not seen by ultrasound. A. Primary and Differential Diagnoses Adenomyosis: A condition in which endometrial tissue exists within and grows into the uterine wall. Adenomyosis often occurs late in the childbearing years and typically disappears after menopause. Sometimes, adenomyosis may cause heavy or prolonged menstrual bleeding, severe cramping, pain during intercourse, or blood clots that pass during a period. Certain medications can help relieve pain or lessen heavy bleeding. Removal of the uterus (hysterectomy) is the only cure. Ovarian tumor: A condition in which endometrial tissue exists within and grows into the uterine wall. Adenomyosis often occurs late in the childbearing years and typically disappears after menopause. Sometimes, adenomyosis may cause heavy or prolonged menstrual bleeding, severe cramping, pain during intercourse, or blood clots that pass during a period. Certain medications can help relieve pain or lessen heavy bleeding. Removal of the uterus (hysterectomy) is the only cure. Endometrial polyp: A usually noncancerous growth attached to the inner wall of the womb (uterus). Endometrial polyps are common in women who are undergoing or have completed menopause. Polyp size varies. Symptoms include irregular menstrual bleeding and bleeding after menopause. Treatments include hormone medications and surgery. P. Uterine fibroids: Also called leiomyomas, are benign smooth muscle tumors of the uterus and occur most commonly in women of African descent. They are sometimes linked to genetic mutations in smooth muscle cells like in the MED12 gene, but estrogen and progesterone also play a role in their development. Most fibroids are asymptomatic, but some cause abnormal uterine bleeding, pain, and fertility issues, Yang et al., 2022. Medical treatment options: Ablation is the removal or destruction of something from an object by vaporization, chipping, or erosive processes. Uterine artery embolization is when an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body. Endometrial ablation is a surgical procedure used to remove or destroy the uterus's endometrial lining in people with heavy menstrual bleeding. It is not recommended for people who wish to have children since complications can occur. Surgical treatment options include: Uterine myomectomy: removal of noncancerous fibroids in the womb, hysterectomy: removal of the uterus. Laparoscopic surgery uses a video camera and thin tubes inserted into small cuts in the body to repair or remove tissue. After scanning through all these informational options above, this patient chose a myomectomy, which was the best option for her per her gynecologist. The patient is scheduled for surgery in two weeks. The patient is scheduled for a follow-up with her gynecologist post-surgery. Health education: education given to patients with fibroids concerning foods they could eat, which includes eating lots of fruits like apples and tomatoes and cruciferous vegetables like broccoli and cabbage to prevent uterine fibroids from reoccurring. Also, eating healthier choices and vegetables and whole grain fruits will help to improve symptoms, Tinelli et al., 2021. References Ali, M., Raslan, M., Ciebiera, M., Zaręba, K., & Al-Hendy, A. (2022). Current approaches to overcome the side effects of GnRH analogs in the treatment of patients with uterine fibroids. Expert Opinion on Drug Safety, 21(4), 477-486. Hesley, G. K., Gorny, K. R., & Woodrum, D. A. (2013). MR-guided focused ultrasound for the treatment of uterine fibroids. Cardiovascular and interventional radiology, 36(1), 5-13. Tinelli, A., Vinciguerra, M., Malvasi, A., Andjić, M., Babović, I., & Sparić, R. (2021). Uterine fibroids and diet. International journal of environmental research and public health, 18(3), 1066. Yang, Q., Ciebiera, M., Bariani, M. V., Ali, M., Elkafas, H., Boyer, T. G., & Al-Hendy, A. (2022). Comprehensive Review of Uterine Fibroids: Developmental Origin, Pathogenesis, and Treatment. Endocrine Reviews, 43(4), 678-719.