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Please reply to the following discussion with one or more references. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite resources in your responses to other classmates.  

Responses must consist of at least 350 words (not including the greeting and the references), do NOT repeat the same thing your classmate is saying, try to add something of value like a resource, educational information to give to patients, possible bad outcomes associated with the medicines discussed in the case, try to include a sample case you’ve seen at work and discuss how you feel about how that case was handled. Try to use supportive information such as current Tx guidelines, current research related to the treatment, and anything that will enhance learning in the online classroom.

References must come from peer-reviewed/professional sources (No WebMD/Mayo Clinic or Wikipedia please!).

Discussion attached

Thanks

Jessica Alper

SOAP NOTE FOR PCOS

Name:  J. Q. 

Date: 11/20/2022

Time: 09:15am

 

Age: 23

Sex: Female

SUBJECTIVE

CC:  

“My menstrual cycle is very heavy and painful, and sometimes I don’t have a period at all”

HPI:  Use OLDCART acronym

Patient complains that she has always been very irregular with her menstrual cycles, and that she never knows when to expect it. She further explains that she sometimes does not have a cycle for about 3 or 4 months, and when she finally has a cycle, the bleeding lasts for 7-9 days and it is very heavy and painful. She states she saturates about 6 to 8 pads per day during the first 6 days, until it finally starts getting lighter. She gets very bloated and nauseous during her cycle as well. Has recently not had a period in 2 months. She takes 600mg of ibuprofen 3 to 4x a day with slight relief. States she also uses a heat pad  to her lower stomach during her cycle to help alleviate the pain. 

Medications: 
(list with reason for med) write medicine the same way you write a Rx)

· Multivitamins 1 PO QD for immune system

· Zoloft 50mg 2 PO QD for depression

· Buspirone 7.5mg 1 PO BID PRN as needed for anxiety

PMH (list approximate year of Dx of the disease or when surgical procedure performed)

Allergies: NKDA, denies food allergies

Medication Intolerances: Denies

Chronic Illnesses/Major traumas: Anxiety (2017), depression (2017)

Hospitalizations/Surgeries: Wisdom teeth (2019)

 

Family History (list immediate family, age, disease, and whether is dead or alive)

States that her mother (45) recently moved here from Texas, and she lives close by. Her mother has hypothyroidism, hypertension, and diabetes and takes all her medications as prescribed. No cancers on maternal side. She never met her father and is unsure of any family history on his side. 

Social History

General: Born and raised in Texas but moved to FL to start college in 2018. 

Marital status: Single, has a boyfriend of 2.5 years.

Living situation: Lives in an apartment with her current boyfriend who attended the same college.