Clinical Intervention-Endometriosis

Your Evidence-Based Clinical Intervention should be submitted in a Microsoft Word document following APA style and should include the following:

The medical problem/diagnosis/disease. (I want to talk about Endometriosis)

Typical presenting signs and symptoms including:
Onset, Characteristics, Location, Radiation, Timing, Setting, Aggravating factors, Alleviating factors, Associated symptoms, Course since onset, Usual age group affected
Concomitant disease states associated with the diagnosis

The pathophysiology of the problem.

Three differential diagnoses and the usual presenting signs and symptoms in priority sequence with rationales.

Reference to at least two current journal articles that show evidence-based practice as how to best treat this disorder related to the primary differential.

The expected outcomes of the intervention.

Algorithms if available.

A typical clinical note in SOAP format. (sample soap note attached)

SOAP NOTE

Name: CL

Date: 9/24/19

Time: 1000

Age: 54

Sex: Female

SUBJECTIVE

CC:

“I’m still having fevers and just feel icky”

HPI:

The patient is a 54-year-old female who is a former paramedic who presents for office visit complaining of generalized weakness, cough and fever that began 4 weeks ago. She was recently diagnosed with Bilateral upper lobe pneumonia at the ER 4 weeks ago. At that time, providers recommended hospitalization, but she refused because she is the primary caregiver for her elderly father. Symptoms have stayed the same since onset. She feels like she isn’t moving much air but denies any nausea, vomiting, or diarrhea. She has seen pulmonary since ER visit and was started on Levaquin and prednisone but then changed to Avelox last week here in the office. Pt describes Symptoms associated with fever, chills, and cough along with green sputum production. Symptoms of fever has improved with tylenol but the fever comes back. Her coughing exacerbates her chest pain. She denies any heart palpitations, diaphoresis, dizziness/syncopal episodes or n/v. Pertinent medical history includes COPD and hypertension. Patient adds she would like to consider home health to receive IV antibiotics through her chest port.

Medications: (list with reason for med )

Tylenol Extra Strength 500 mg Caplets, 2 tabs q4-6 hr for fever

Abilify 20mg daily

Baclofen 10mg daily

Clonazepam 1mg QID PRN

Fluoxetine 40mg daily

Lasix 40mg daily

Gabapentin 600mg daily

Klor-Con M10 meq daily

Lisinopril 40mg daily

Losartan/HCTZ 100/25 daily

Metoprolol tartrate 100mg TID

PMH

Allergies: Codeine

Medication Intolerances: Denies

Chronic Illnesses/Major traumas: Von Willebrand disorder, hypertension, anxiety, bipolar disorder, Vitamin D deficiency, COPD, PVD, insomnia.

Hospitalizations/Surgeries: Appendectomy (2001)

Family History

Mother-(deceased): COPD, Hypertension, MI, hypothyroidism

Father-(alive): dementia, anxiety/depression, CHF, CAD, HTN

Social History

General: Born and raised in Great falls, SC.

Marital status: Married

Living situation: Her father lives in the home with the patient’s family.

Children: 17year old boy and 12-year-old girl.

Occupation: Teacher at local elementary school.

Leisure Patterns: Pt states she reads a book when she gets a chance

Social habits: Denies smoking or alcohol consumption. Does not exercise.

Spirituality: Christian

Nutrition: Balanced diet. She mostly cooks at home and rarely eats fast food.

Sleep Patterns: States that she usually gets about 5hrs of

ROS

General

Reports weakness, fatigue, or fever. Denies headache, head injury, dizziness, or lightheadedness.

Cardiovascular

Denies any troubles with her heart, rheumatic fever, or heart murmurs. Denies having chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema.

Skin

Denies rashes, lumps, sores, itching, and changes in color. Denies changes in his nails or hair. Denies changes in size or color of moles.

Respiratory

Reports cough, yellow-greenish sputum, wheezing, and SOB that worsens at night.

Eyes

Denies any changes in her vision. Does not use glasses. Denies any pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma or cataracts.

Gastrointestinal

Denies trouble swallowing, heartburn, changes in appetite, or nausea. Denies pain or bleeding with defecation. No changes in bowel habits. Denies black or tarry stools, hemorrhoids, constipation, or diarrhea. Denies abdominal pain, food intolerance or excessive belching or passing gas.

Ears

States she doesn’t have any hearing problems. Denies tinnitus, vertigo, earaches, infection, or discharge. Denies use of hearing aides.

Genitourinary/Gynecological

Goes to the bathroom 4 or 5 times a day. Denies polyuria, nocturia, urgency, burning or pain during urination. Denies hematuria, urinary infections, kidney or flank pain, kidney stones, urethral colic, suprapubic pain, or incontinence. No changes in bladder habits.

Menarche at age 13. States she gets her period approx. q 28 days and it lasts about 5 days. Flow heavier on the first 2 days. Denies bleeding between periods. LMP: September 4th. Denies PMS. Denies any vaginal discharge, dyspareunia, itching, sores, lumps, or STDs. G1 P1, spontaneous vaginal delivery at 39 weeks. Denies any complications with her pregnancy. Denies use of birth control methods. Not sexually active at the moment. Has had one partner in the past 5 years. Denies exposure to HIV infection or STDs.

Nose/Mouth/Throat

Pt states she gets occasional allergies and colds that cause her to have stuffiness and discharge. Denies hay fever, nose bleeding, or sinus trouble. Throat: States her teeth are yellow and sometimes her gums would bleed. Denies use of dentures. Last dental examination 2 yrs ago (Oct/15). Denies sore tongue, frequent sore throats or hoarseness. Denies having dry mouth or excessive thirst.

Neck: Denies swollen glands, goiter, lumps, pain, or stiffness in the neck.

Musculoskeletal

Denies muscle weakness, paresthesia, loss of sensations, no severe or progressive neurological deficit in lower extremity. No Hx of cancer, or risk factors for spinal infection (no IV drug abuse, UTI, Immune suppression). Pt reports feeling lower back pain that started yesterday while at work that is worse in the R lumbo-sacral area. Pain radiates to her R buttock. Pt states it hurts to stand up or find a comfortable position. States her back hurts even at rest, but pain gets worse when she moves. Pain worsens after bending or lifting. Denies other muscle or joint pain, stiffness, arthritis or hx of gout. Denies fever, chills, rash, anorexia, weight loss or weakness.

Breast

Denies lumps, pain, discomfort or nipple discharge.

Neurological

Denies changes in mood, attention or speech. Denies changes in orientation, memory, insight, or judgment. Denies headaches, dizziness, vertigo, fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements.

Heme/Lymph/Endo

Denies anemia, easy bruising or bleeding, and past transfusions. Denies excessive thirst and hunger. Denies thyroid trouble, heat or cold intolerance, excessive sweating, polyuria or changes in shoe size. Denies weight changes or fever.

Periferal Vascular: Pt states she has a few spider veins that look like bruises, she got them during the pregnancy. Denies leg cramps, varicose veins, past clots in veins, swelling in calves, legs or feet. Pt states there have not been any changes in the color of her fingertips or toes during cold temperatures/weather. Denies any swelling or tenderness.

Psychiatric

Denies nervousness, tension, mood changes, depression, or memory changes.

OBJECTIVE

Weight 120lbs BMI 20

Temp 98 F

BP 114/74

Height 67”

Pulse 89

Resp 20

General Appearance

Skin warm and dry w/o discoloration or pallor, A/O x 3, appropriate responses, cooperative, appears concerned w/o signs of acute distress.

Skin

Skin is warm, pink and supple, no lesions noted.

HEENT

Normocephalic, PERRLA, EOMs intact, fundoscopic: red reflex present, no nicking or hemorrhage. TM intact bilaterally, pearly with + light reflex. Nares patent, neck supple. Pharynx: swallows w/o difficulty, no erythema; Neck: thyroid non palpable, no carotid bruits.

Cardiovascular

Carotid upstrokes are brisk, w/o bruits. The PMI is tapping, 7cm lateral to the midsternal line in the 5th intercostal space. S1 louder than S2 on auscultation. No murmurs or extra sounds. Extremities are warm and w/o edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+ , brisk, and symmetric.

Respiratory

Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or ronchi.

Gastrointestinal

Abdomen is flat with active bowel sounds in all four quadrants. It is soft and non-tender; no masses or hepatosplenomegaly. No CVA tenderness.

Breast

Deferred

Genitourinary

Deferred

Musculoskeletal

No joint deformities. Positive ROM in hands, wrists, elbows, shoulders, knees and ankles. Gait/Posture: Flexed forward at 15º, walked slowly with a wide based stance, and grimaced with movement. Heel and toe walking intact. Spinal column: No kyphosis, scoliosis or lordosis; unable to extend or rotate. Lateral movement: bilaterally to 20º. All attempts at ROM produced pain. Right paravertebral muscle spasm noted in lumbar area. Straight leg raise (SLR) negative, Patrick test negative, crossed SLR negative. No noted major motor weakness on knee extension, ankle plantar flexors, evertors, dorsiflexors. No CVA Tenderness.

Neurological

Cranial nerves II to XII intact. Good muscle bulk and tone. Strength 5/5 throughout. Rapid alternating movements and point to point movements are intact. Gait stable. Pinprick, light touch, position sense, vibration, and stereognosis intact, Romberg negative. Reflexes 2 + and symmetric with plantar reflexes down going.

Psychiatric

Alert, relaxed and cooperative. Thought process is coherent. Oriented to person, place and time.

Lab Tests

None ordered today.

Special Tests

None ordered today.

Diagnosis

Diagnosis:

1. Acute lumbosacral strain (M54.5)

Differentials:

1. Acute lumbosacral pain (M54.5): Minimal discomfort initially followed by increased pain and stiffness 12-36 hrs later, SLR, crossed SLR, heel and toe walking were intact. No muscular weakness or loss of sensation. DTRs were equal and not depressed. Babinski negative. Spasm noted in paravertebral muscles.

2. Herniated lumbar disc (M51.2): Pain in buttocks.

3. Sciatica (M54.3): Pain in back/buttocks.

4. Possible vertebral Fx (S32.009A): Low back pain.

Plan/Therapeutics

Plan:

Diagnostic: No tests needed at this time

Therapeutic: Pharmacological:

D/C OTC Tylenol. Start Ibuprofen 600mg 1 po q8h x 7 days then PRN for pain. Robaxin 500mg 1 po QAM, 2 po QHS x 2 weeks then 1 po Q8H PRN for back pain.

Non-pharmacological:

Local application of ice may help initially to decrease pain, apply cold pack for 20 minutes q2-3 hours while awake. After 2-3 days, either heat or ice may be applied. No bed rest indicated. Take 3-7 days off work (her job would increase stress on her back), or perform other duties until the symptoms abate.

Patient Education:

1. Avoid jerky, hurried movements when lifting

2. Lift with legs by straddling the load; bend knees to pick up load; keep back straight (do not bend back)

3. Keep objects close to the body at navel level when lifting

4. Avoid twisting, bending, reaching while lifting

5. Avoid prolonged sitting

6. Change positions often while sitting

7. A soft support belt for the back, armrests to support some body weight, a slight reclining chair may make sitting more comfortable

8. Firm mattress/bed board, lying supine with hips and knees flexed on pillows is beneficial when sleeping

9. May return to work in 4-8 days

10. As soon as she returns to regular activities (in 2 weeks), aerobic conditioning exercises such as walking, swimming, stationary biking, or even light jogging may be recommended to avoid debilitation.

Referral: None

Follow-Up: Come back if the pain does not improve by 50% in 24-48 hrs. Return to the office in 7-10 days. Return sooner if neurological symptoms worsen or bowel/bladder dysfunction occurs.

Evaluation of patient encounter:

I was able to assess the patient independently and then later present the case to my preceptor by providing her with the pertinent positive on the ROS and on the physical exam findings. I participated in the Dx selection and in the treatment plan.

Weaknesses: I must by managing my time. It took me almost 45 minutes to work on this case.

Strengths: I have improved my physical exam skills, I feel confident and comfortable interacting with patients on my own.

Reflection: I feel like I am improving with collecting enough information and with performing focused physical exams. I feel like everything is starting to fall in the right place.

References:

Bickley, L. (2007). Bates’ Guide to Physical Examination & History Taking (9th Edition), Lippincott, Williams and Wilkins Publishers

National Guideline Clearinghouse. (2008). Management of Acute Low Back Pain. Retrieved November 10, 2008 from http://www.guideline.gov/summary/summary.aspx?doc_id=12491&nbr=006422&string=back+AND+pain

Uphold C, Graham M. Clinical Guidelines in Family Practice. 4th ed. Gainesville, Fl: Barmarrae Books Inc; 2003:370-376.