iHuman Patient Elizabeth Walker Reflection

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iHuman Patient Elizabeth Walker Reflection

Steps to Differential Diagnosis

Acute pelvic pain in women is a high-intensity pain in the lower body quadrants existing not more than 3 months. For the case of Elizabeth, differential diagnoses for acute pelvic pain could be due to gynecologic and non-gynecologic causes. Differential diagnosis of the cause, as explained by Brady & Carusi (2016), is usually based on proper history taking and physical examination. A proper history taking from the patient gave pain characteristics, the sexual and social history of the patient, age and review of systems that guided the differential diagnoses.

Steps to Final Diagnosis

To reach the final diagnosis, a thorough physical examination is needed to rule out the other differential diagnoses. According to Hecht et al. (2019), clinical examination and blood tests are essential; in complementing patient history in the diagnosis of pelvic pain causes. The presence of fever and chills and vaginal discharges in the patient could suggest a systemic infection like Pelvic inflammatory disease. Elizabeth does not show inappetence, vomiting or worsening pain during bowel movement, which rules out chances of digestive tract disorders like appendicitis. Lack of vaginal bleeding and negative HCG test rule out ectopic pregnancy. Ultrasonography remains the modality of choice in making the final diagnosis after a thoroughly complete and systemic clinical and physical examination (Hecht et al., 2019). Enlargement of the right ovary without blood flow on ultrasound exam is definitive for ovarian torsion.

Application of Watson Theory

Proper management of the condition involves educating the patient on causative factors and assure her of being well again. The Watson theory explains the importance of self-healing when the patient’s emotional needs are met by providing a caring attitude and a healing environment. The nurse can listen to the patient to appreciate her beliefs about the condition, and maintain a trusting and respectful interpersonal relationship with her. Nurses can also attend to the spiritual needs of the patient, and respond to all her fears raised during management, like the possibility of developing infertility after surgery (Pajnkihar et al., 2017). In this case, the patients’ needs to know about the corrective surgical procedure, and the effect of that on her overall health. The patient’s spiritual needs should be explored, and let her know that she will be well after the surgical correction.

Management

Ovarian torsion occurs when the ovary twists over the supporting ligaments, obstructing the flow of blood to the ovary and causing local inflammation. Diagnosis of the condition is important to prevent ischemia of the ovary and associated infertility issues. Treatment of the condition is usually surgical detorsion with adnexal sparing (Guile & Mathai, 2021). Proper analgesia controls tachycardia and helps in relieving the acute pain before surgery.

Conclusion

Acute pelvic pain can be caused by both gynecologic and non-gynecologic factors. In most cases, an immediate diagnosis is important to prevent further injuries which may complicate the condition and predispose patients to secondary conditions. A proper clinical and physical examination is important in the effective diagnosis of causes of acute pelvic pain in women, and management should be taken into keen consideration of patients’ needs and values.

References

Brady, P. C., & Carusi, D. (2016). Acute Pelvic Pain. Handbook of Consult and Inpatient Gynecology, 3-29. https://link.springer.com/chapter/10.1007/978-3-319-27724-0_1

Guile, S. L., & Mathai, J. K. (2021). Ovarian Torsion. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK560675/

Hecht, S., Meissnitzer, M., & Forstner, R. (2019). Acute Pelvic pain in women-gynaecological causes. Der Radiologe59(2), 126-132. https://doi.org/10.1007/s00117-018-0475-4

Pajnkihar, M., Štiglic, G., & Vrbnjak, D. (2017). The concept of Watson’s carative factors in nursing and their (dis) harmony with patient satisfaction. PeerJ5, e2940.  https://dx.doi.org/10.7717%2Fpeerj.2940

 

SOAP Note Template

ID

First Name Elizabeth

Last Name Walker

Gender Female

Age 34

CC

Abdominal pain RLQ one hour with nausea. Reports pain is stabbing, sharp, strong, feels deep, rates pain 8 on scale 0-10.

HPI

History (including PMH, surgical, family, and social)

Elizabeth Walker is a 34-year-old married female who presents for evaluation of acute onset of RLQ abdominal pain with nausea for one hour. She characterizes the pain as sharp, constant, and worse with any movement. She reports associated nauseas, denies vomiting, fevers/chills, diarrhea, abnormal vaginal bleeding or discharge, lower urinary tract symptoms, or flank discomfort. PMH is notable for her currently undergoing hormonal stimulation fertility treatments (G0P0). The physician exam is significant for tachycardia, RLQ pain with guarding and rebound, as well as a tender right adnexal mass per pelvic examination. Other active problems: Infertility – takes HCG injections and FSH. Obstetric History: Gravida 0, Para 0, Abortus 0. Surgical History: 1. Tonsillectomy – @ age 14. Preventive: Flu immunization recommended yearly. BMI to 22.3 Seat belts – uses regularly. Texting while driving – never. Current on immunizations:1) up to date on Tdap. 2) up to date on influenza vaccination. Family History: Mother – 62 with HTN, alive and well. Father – 65 with diabetes, alive and well. Sister – 36 with two children, alive and well. Grandparents – deceased unknown causes. Social History: Tobacco – none. Alcohol – no. Recreational drugs – none. Married – monogamous. Education – college graduate. Job – elementary-school principal. Travel – none recently. Pets – none. Home safety – no guns in household.

ROS (general, skin, HEENT, neck, breasts, resp, CV, GI, peripheral vascular, urinary, genital/LMP, MSK, psych, neuro, hematologic, endocrine)

General: No evidence of fever, chills, fatigue, malaise, night sweats, excessive or unexplained weight gain or loss. Skin/Breasts: No rashes, bruising, jaundice, pruritis, acne, sores, ulcers, changes in moles, hair loss or brittleness, nails. No pain from her breasts. No lumps on bilat breasts. Does monthly self-breast exam. No discoloration near nipples or breasts. No nipple discharge. Periods are regular every 26-28 days. LMP three weeks ago. Uses three pads or tampons per day. HEENT/Neck: Denies vision changes, blurred vision; eye pain, discharge, itching, or redness. Denies ear pain, ear discharge, hearing difficulty, vertigo, nasal congestion, epistaxis, sinus pain or pressure, sore throat, swollen glands in neck, tooth pain. Cardiovascular: No complaints of chest pain/pressure, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, palpitations, ankle swelling. Resp: Denies shortness of breath, wheezing, cough/ sputum, hemoptysis, tightness in chest, pleuritic chest pain (pain with deep breath or cough). Abd/GI: C/o nausea and RLQ abdominal pain for last hour. No problems with appetite changes, dysphagia, vomiting, hematemesis, heartburn, diarrhea, constipation, melena. GU: No menstrual irregularities, amenorrhea, dysmenorrhea, dyspareunia.  Denies dysuria, urinary frequency, nocturia, hematuria, incontinence, urgency, hesitancy, difficulty starting or stopping stream. MSK: No joint or muscle pains, joint stiffness and swelling, limitations in movement, functionality. Neuro: No problems with headaches, syncope, presyncope, dizziness, weakness, paralysis, numbness/tingling, or balance. Allergic/Immunologic: Denies food allergies, hives, or rashes. Lymphatic/Endocrine: Denies polyuria, polydipsia, polyphagia, tremor, heat or cold intolerance, hot flashes. Hematologic: Denies excess bruising or bleeding, swollen glands/lymphadenopathy. Psychological: No problems with mood changes, feeling depressed, manic behaviors, auditory or visual hallucinations, anxiety, insomnia, suicidal or homicidal ideations.

Allergies

Penicillin. NKFA.

Current Medications

FSH and HCG injections.

Objective

Vital Signs:

BP 106/70 mmHg – sitting.

RR 14 unlabored

Pain 8

Height 5’ 4”

Weight 130 lbs. (59.1kg)

BMI 22.3

Temp 98.6 oral

Pulse Ox 99% room air

Physical exam (general, HEENT, neck/lymph, breasts, chest/respiratory, CV, GI/abdomen, GU/rectal, back, MSK, skin, neuro, psych)

Weight:  130.0 pounds. Skin/Breasts: Atraumatic, good skin turgor, skin, and scalp normal, no evidence of suspicious pigmented lesions. Normal symmetrical breast contour bilat. No overt inflammatory signs. No previous incisions or trauma. Left and right breast with no abnormalities. No axillary adenopathy. No expressible nipple discharge. HEENT: Eyes: Sclera and conjunctiva normal. Pupils and irises size symmetrical and shows normal reaction to light and accommodation bilaterally. Ears: no external scars or lesions. Otoscopic exam normal with only minimal wax, no masses or foreign bodies, good light reflex bilaterally. Nose: External without abnormality. Normal nasal mucosa, septum, turbinate’s. Mouth: Good dental hygiene. Neck supple, no adenopathy, trachea midline, no carotid bruits, thyroid size 25 gm, no masses or tenderness. Cardiovascular: No JVD. No thrills, heaves, or lifts. PMI normal size and location.  Heart RRR Normal S1 and S2, no murmurs appreciated. No carotid bruits, abdominal aorta normal size no bruits, pedal pulses present and symmetrical, no evidence of peripheral edema or varicosities. Respiratory: Normal chest shape, normal respiratory movement, no tenderness, and percussion normal. Auscultation found normal breath sounds throughout without wheezing, rales or ronchi. Abdomen/GI: Flat contour. No scars. Normal bowel sounds present. No hepatosplenomegaly. Severe tenderness to RLQ palpation below McBurney’s point, with associated guarding and rebound; no palpable mass. Mild tenderness to RUQ and LLQ palpations. No CVA tenderness. Liver edge felt below the coastal margin, span normal to percussion. Spleen normal size. GU/GYN: No lesions on external exam. Speculum exam: no blood or discharge present, cervix appears normal. Bimanual exam: right adnexal tenderness with palpable mass. No cervical motion tenderness. Normal genitalia, no evidence of infection. MSK: Normal ROM and muscle tone throughout. Muscle strength and flexibility throughout axial and appendicular skeleton normal. Motor 5/5 all extremities. Neurological: A & O x 4, good attention, memory, normal gait, CN 2-12 intact, reflexes 4/4 throughout. Normal cerebellar exam with finger to nose (FTN), rapid alternating movements (RAM), heal to shin (HTS) bilaterally. Allergic/Immunologic: No worrisome preauricular, posterior auricular, anterior cervical, posterior cervical, submandibular, supraclavicular lymph nodes. Lymphatic/Endocrine: Thyroid normal to palpation, 25 gm, no masses or tenderness. Hematologic: Normal capillary refill. No evidence of anemia.

Problem List:

  • Right Ovarian Torsion

 

Differential diagnoses:

Differential Diagnoses How Was This Diagnosis Ruled Out?
Ectopic pregnancy
Tubo-ovarian abscess
Ovarian cyst rupture
Appendicitis
Ovarian torsion

Include the following:

  • Medications to be prescribed (drug-dose directions)
  • Instructions to continue, discontinue, or start medications, including changes to routine medications.
  • Diagnostic tests in the proper order and reason for the order (e.g., CT abdomen and pelvis with and without contrast, Dx, LLQ abdominal pain)
  • Labs, including appropriate serum panels (e.g., BMP, CBC with diff., TSH, T4, UA, C&S)
  • Patient education pertinent to health condition
  • Follow-up plan
  • Referrals
Plan Rationale and/or results
Pelvic Ultrasound Results show an enlarged right ovary with no blood flow is diagnostic for ovarian torsion.

Right ovary 11cm x 4cm with small cyst. No blood flow to right ovary seen.

Left ovary 4cm overall size. No pathology identified.

CBC
Name Value Units Reference Range
White blood cells (WBCs) 11200 mm3 4,000-10,000
Red Blood Cell Count (RBC) 4.9 million/µl 4.5-5.9(♂), 4.0-5.2(♀), adults
Hemoglobin (Hgb) 12.2 g/dl 14-18(♂), 12-16(♀), adults
Hematocrit (Hct) 38.4 % 42-54(♂), 37-47(♀), adults
Mean corpuscular volume (MCV) 91 fl 82-103, adults
Mean corpuscular hemoglobin (MCH) 28 µm3 26-34, adults
Mean corpuscular hemoglobin concentration (MCHC) 31 % 30-37, adults
Platelets (thrombocytes) 280 k/dL 150-399, adults
Red cell distribution width (RDW) 12.0 % 11.5-14.5, adults
Neutrophils 74 % 46-78, adult
Lymphocytes 23 % 18-52, adult
Monocytes 1 % 3-10, adult
Eosinophils 1 % 0-6, adult
Basophils 1 % 0-3, adult
Segmented neutrophils 72 % 36-72, adult
Band Cells 2 % 0-6, adult
hCG, urine
Name Value Units Reference Range
Human chorionic gonadotropin (HCG), urine Negative None (♂ and non-pregnant ♀); detectable (pregnant ♀)
UA
Name Value Units Reference Range
Color Amber Interpreted by physician
Clarity Clear clear
Odor Normal slightly nutty
pH 5.4 4.5-8
Protein 1 mg/dL 0-8
Specific gravity 1.019 1.002-1.030
Osmolarity > 400 mOsm/L >400
Leukocyte esterase Negative negative
Nitrites Negative 0
Ketones Negative negative
Bilirubin Negative negative
Blood (heme) Negative negative
Urobilinogen 0.5 EU/dL 0.2-1.0
Crystals None Interpreted by physician
Casts 0-1 hyaline casts/lpf 0-4
Glucose, urine Negative negative
White blood cells (WBCs) 0-1 hpf 0-5
Red blood cells (RBCs) 0-1 hpf 0-5
Red blood cell casts None none
SQEP 0-1 lpf <5
Bacteria Negative negative on spun specimen
Creatinine 8 5-19
Occult blood Negative negative
STAT GYN surgical referral for removal of right torsed ovary STAT. Start IV access to provide for analgesia. Order blood work for chemistries and coagulation studies as part

Of the preoperative workup. Monitor vital signs. Patients’ tachycardia will most likely improve with

Analgesia and pain control. Prep for emergent laparoscopy to detorse the ovary and thereby restore

Perfusion.

Referral for education, counseling, supported decision making and support groups for infertility and loss of ovary.
Name Value Units Reference Range
Human chorionic gonadotropin (HCG), urine Negative None (♂ and non-pregnant ♀); detectable (pregnant ♀)

NRP/563: Management Of Women’s Health Issues

Wk 7 – iHuman Patient Elizabeth Walker Reflection

  1. See attached SOAP note for Elizabeth Walker.
  2. Write a 500-word summary (7th edition APA format) regarding your patient encounter with Elizabeth Walker.
  3. Include the following in your summary:
  • Explain how you arrived at your differential diagnoses.
  • Explain the steps you used to determine the final diagnosis.
  • Give examples of how you can integrate cultural preferences, values, health beliefs, and behaviors into the treatment plan using Watson’s theory.
  • Describe the appropriate management (e.g. health maintenance, diagnostics, medications/treatment) and support with evidence.
  • Critique your overall case evaluation, highlighting 2 to 3 takeaways to improve your clinical skills now that the diagnosis has been revealed.
  1. Cite a minimum of 3 peer-reviewed journal references within the last 5 years supporting your responses according to 7th edition APA guidelines.
  2. Course Textbooks:
  • Schuiling, K. D., Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Jones & Bartlett Learning.
  • Dunphy, L. (2019). Primary care: The art and science of advanced practice nursing (5th ed.). F.A. Davis.

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