Mallory Miner

SOAP Note #2
Identification:
LP: 21 y.o Caucasian Female
Date of Visit: 02/09/17
BYU-Idaho Student Health Insurance
Subjective:
Chief Complaint: I feel like I have all the signs of being pregnant.
History of Present Illness:
Pt has been trying to get pregnant for 7 months. Pt reports she has never had
a "late" period. Regular menses, 28 day cycle. This is the first time it has
been more than a day late. Home pregnancy tests 1/day x 8 days negative
results. Period is 11 days late as of 02/09/17. Pain at 2/10 and is cramp
related. Pt reports light cramping, no blood.
Reports large amount of clear vaginal discharge. Reports nausea worse in the
AM. Denies vomiting. Mother pertinent for history of negative pregnancy
tests, when actually pregnant. Pt requesting pregnancy blood test. Last Depo-
Provera shot in May 2016. Takes prenatal vitamins (over the counter) by
mouth daily for the past 7 months. Weight has fluctuated with start and stop
of Depo overall has gained 10lbs in past 7 months.

Past Medical History:

No seizures, No asthma, No cardiac issues, No anxiety/depression
Menarche: 11, periods are normally heavy on the 1st day and then are
regular flow, every 28 days, cramps are heavy on the first day and then
subside.
Birth control: Depo-Provera shot February and May 2016
Past Surgical History:
Wisdom Teeth 2011
Tonsillectomy 2001
Family History:
Mom: Thyroid Removed 2015, right knee replacement 2001.
Dad: Alive and Healthy
Siblings: 5 total, 3 brothers, 2 sisters. All have hx of depression/anxiety and
are being tx with counseling and medications. One sister has thyroid issues.
 Extended paternal family hx positive for type 2 DM.
Allergies:
NKDA
None.
Medication:
Prenatal Vitamins
Social History: Pt is originally from upstate New York and served an LDS mission in
Argentina. She met her husband at school and got married in May 2016. She and
her husband are college students attending BYU-Idaho. She lives off campus in a
married housing complex. Her major is Social Work and she enjoys dancing. She and
her husband share a car. She does not have any pets. She and her husband are
sexually active and are currently trying to get pregnant. Denies other sexual
partners. Denies alcohol, drug, or tobacco use.
Immunizations: Up to date. Last influenza vaccine 11/2016.

Review of Systems
Generalized: Pt reports frustration understanding why she is not pregnant. Denies
fevers, chills, fatigue.
Respiratory: Denies shortness of breath, dyspnea or cough.
Cardiovascular: Pt does not regularly check her BP. Denies chest pain or
palpitations.
Gastrointestinal: Complains of nausea, change in bowel habits, abdominal pain.
Denies vomiting, diarrhea, constipation, melena, hematochezia, jaundice. Reports
regular, soft, bowel movements.
Urinary: Denies incontinence, dysuria, hematuria, urinary frequency.
Reproductive: Complains of clear vaginal discharge, amenorrhea, and lower
abdominal pain related to menstrual cramps. Denies menorrhagia, abnormal vaginal
bleeding.
Vital Signs:
Height: 66in.Weight: 242.9lbs. KG: 110.18 BMI (in-lb) 39.35 BSA 2.17
BP: 136/ 70 SP02 : 98 Pulse rate: 92 Pain 2/10
Physical Exam
General appearance: well nourished, well hydrated, no acute distress.
Respiratory: Auscultation: no rales, rhonchi, or wheezes.
Cardiovascular: Clear to auscultation: S1, S2, no murmur, rub, or gallop.
Gastrointestinal: Flat soft symmetric appearance, BS active x 4 quadrants.
Reproductive: Exam deferred, pt declined.

Assessment:
1. Other specified irregular menstruation (ICD10-N92.5)
2. Screening for endocrine, nutritional, metabolic disorder (ICD-V77.99) (ICD10-
Z13.9)
3. SCREENING OTHER & UNSPECIFIED DEFICIENCY ANEMIA (ICD-V78.1) (ICD10-
Z13.0)
4. Screening for thyroid disorder (ICD-V77.0) (ICD10-Z13.29)
Differential diagnosis:
Irregular Menstruation:
-Secondary Amenorrhea
-Polycystic ovary syndrome (PCOS)
-Hypothalamic amenorrhea
-Prolactin-secreting pituitary tumors
-Ovarian failure
-High prolactin
-Hypothalamic or pituitary conditions
-Endometrial adhesions (Asherman syndrome)
-Anatomic problems
Screening:
To rule out
-Pregnancy
-DM
-Insulin resistance
-Thyroid Issues
Plan:
Pt was sent to lab because she wanted an hCG blood test. Discussed with patient
that she would also have a urine pregnancy test completed at the clinic now.
Explained that is rare but it is possible to have a negative urine pregnancy test and
a positive hCG blood test.
Discussed with patient that we are looking for other possible causes of amenorrhea
and other pathologic causes that may be interfering with her ability to become
pregnant.
1. Irregular Menstruation Education:
Encouraged patient to continue to monitor periods.
Encouraged to continue trying to lose weight.
Discussed with patient the importance of drinking plenty of water and eating a
healthy diet.
The urine pregnancy test was negative.
2. Screening for endocrine, nutritional, metabolic disorder
Test:
CBC Idaho INH [i85025inh]
CMP Idaho INH [i80053inh]
CBC (70)
WBC 4.1 x10 4.0-12.0
%Neu 46.7 % 43.0-76.0
%Ly 40.2 % 17.0-48.0
%Mon 8.0 % 4.0-13.0
%Eos 1.8 % 0.0-6.0
%Bas 0.2 % 0.0-1.2
RBC 4.32 x10 3.80-5.80
HGB 13.1 g/dL 11.3-15.3
HCT 38.9 % 38.0-44.0
MCV 90 fL 80-98
MCH 30.2 pg 26.5-33.5
MCHC 33.6 g/dL 31.5-35.0
RDW 13.6 % 10.0-15.0
PLT 205 x10 150-450
MPV 8.4 fL 6.5-11.0
#Neu 1.9 x10 1.4-6.5
#Ly 1.6 x10 1.2-3.4
#Mon 0.3 x10 0.1-0.9
#Eos 0.1 x10 0.0-0.
#Bas 0.0 x10 0.0-0.1

Tests: (2) CMP w/GFR (22)

Sodium 142 mEq/L 137-145
Potassium 3.9 mEq/L 3.5-5.1
Chloride 100 mEq/L 98-107
Carbon Dioxide (CO2) 28.0 mEq/L 22.0-30.0
Glucose, Serum [L] 52 mg/dL 74-100
BUN 16 mg/dL 7-17
Creatinine [L] 0.6 mg/dL 0.7-1.2
Total Protein 6.9 g/dL 6.3-8.2
Albumin 4.2 g/dL 3.5-5.0
Calcium 10.2 mg/dL 8.4-10.2
Total Bilirubin 0.60 mg/dL 0.20-1.30
AST (SGOT) 38 U/L 22-58
ALT (SGPT) 44 U/L 9-52
Alkaline Phosphatase 57 U/L 50-145
Globulin 2.7 g/dL 2.0-4.8
A/G Ratio 1.6 Ratio 0.6-2.2
B/C Ratio 26.7 Ratio 8.0-36.0
GFR (5.1) 126.2
Order Note: The average blood glucose level is 90.
3. Screening other & unspecified deficiency anemia
Test:
hCG/Quantitative [431]
Hemoglobin A1c [300] 5.9
Order Note: HCG was <2.1, which is negative.
4. Screening for thyroid disorder
 Test:
TSH w/Reflex FT4 [2] [1029]
Order Note: none.
Plan: Educated patient regarding insulin resistance and its effects on weight, energy
level, and menstrual cycles.
Screening labs done today, results pending.

Mallory Miner, DNP Student

Follow up: Pt notified that the HCG was <2.1, which is negative. The lab tests
indicate that she is NOT pregnant. Encouraged pt to make a follow up appointment
if she would like to discuss insulin resistance (pre type 2 diabetes) in relationship to
her skipped period.
Evidence Based-Practice: The hierarchy of evidence is used to determine the best
research. The article I chose for this SOAP note is Metabolic effects of lifestyle
intervention in obese pregnant women. I chose this article because it is a level I on
the hierarchy of evidence. Being a randomized control trial, it is the gold standard
for research.
The Lifestyle in Pregnancy (LiP) study was a randomized controlled trial with 360
obese women (BMI 30-45) in early pregnancy. The research was to see if lifestyle
interventions such as diet counselling and physical activities would improve the
rates of clinical pregnancy complications (Vinter, Jrgensen, Ovesen, Beck-Nielsen,
Skytthe & Jensen, 2014).
Fasting blood samples, including plasma glucose, insulin, lipid profile and capillary
blood glucose during a 2 hour oral glucose tolerance test were carried out three
times throughout pregnancy. This study ran from October 2007 to October 2010 at
two university hospitals in Denmark. Participants were obese women 1840 years
old and were recruited at 1014 weeks of gestation. Some of the inclusion criteria
required a BMI of 3045, which was calculated from the pre-pregnancy weight or
first measured weight in pregnancy. Furthermore, women were excluded if they had
prior serious obstetric complications, major medical disorders including pre-
gestational diabetes, were non-Danish speaking, abuse of alcohol or a multiple
pregnancy.
After receiving written and oral information and giving written consent, the 360
participants were randomized and the pregnancy the intervention group received
four separate diet counselling sessions and an exercise program consisting of
weekly aerobic classes, free fitness membership during pregnancy and exercise
motivating initiatives (Vinter, Jrgensen, Ovesen, Beck-Nielsen, Skytthe & Jensen,
2014).
The women in the intervention group had a significantly lower change in insulin
resistance. There was no difference between the groups with total cholesterol, HDL,
LDL or triglycerides. The authors write that minor improvements in metabolic status
during pregnancy may influence the programming in utero, even if no beneficial
effect is shown on short-term neonatal outcomes. The authors suggest that
prospective follow-up studies in offspring from mothers who participated in
antenatal intervention programs should be performed to address this issue. Finally,
the authors mention that large interventional studies in obese women are ongoing
and should provide further evidence on how to manage obesity in relation to
pregnancy (Vinter, Jrgensen, Ovesen, Beck-Nielsen, Skytthe & Jensen, 2014).
Reflection:
Dr. Arvidson mentioned in my learning goals feedback that I needed to work on
topics or areas that I am weak in. Sometimes it is hard to have difficult
conversations. For example, with this patient, she is overweight and it is affecting
her ability to get pregnant and even though she doesnt want to believe it or think it
is a problem- it is.
Working with this patient made me realize the importance for myself to lose weight.
I weighed in at 199 lbs. and thought to myself- I do not want to get any heavier-but
it never even occurred to me to watch my weight so that I can have healthy
pregnancies.
I try to stay very positive and want to uplift and encourage patients, and so telling
someone that they are overweight is a challenge for me.
We ordered a lot of lab work because this patient was in denial that weight was an
issue. This exam taught me the importance of communicating effectively with our
patients, letting them know that we as providers are here to help, not criticize. I
remember thinking to myself this patient could be me one day. We also talked about
how some women experience difficulty getting pregnant coming off of Depo-Provera
even up to 12 months after their last shot. I really hope that this patient comes back
in and is able to make some more lifestyle changes so that she can start the family
she so desperately wants at this time.

Reference
Vinter, C. A., Jrgensen, J. S., Ovesen, P., Beck-Nielsen, H., Skytthe, A., & Jensen, D.
M. (2014). Metabolic effects of lifestyle intervention in obese pregnant women.
Results from the randomized controlled trial 'Lifestyle in Pregnancy' (LiP). Diabetic
Medicine, 31(11), 1323-1330. doi:10.1111/dme.12548