Common Health Conditions with Implications for Women
Select a patient that you examined during the last four weeks as a Nurse Practitioner. Select a female patient with common endocrine or musculoskeletal conditions, Evaluate differential diagnoses for common endocrine or musculoskeletal conditions you chose .With this patient in mind, address the following in a SOAP Note:
Subjective: What details did the patient provide regarding or her personal and medical history?
Objective: What observations did you make during the physical assessment?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up appointment with the provider, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation? And how can you relate this to your class and clinical readings.
References
Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.). Burlington, MA: Jones and Bartlett Publishers.
Chapter 22, “Urinary Tract Infection in Women” (pp. 535–546)
Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.
Review: Chapter 8, “Primary Care in Women’s Health” (pp. 431–560)
Centers for Disease Control and Prevention. (2012b). Women’s health. Retrieved from http://www.cdc.gov/women/
National Institutes of Health. (2012). Office of Research on Women’s Health (ORWH). Retrieved from http://orwh.od.nih.gov/
U.S. Department of Health and Human Services. (2012a). Womenshealth.gov. Retrieved from http://www.womenshealth.gov/
SOLUTION:
Common Health Conditions with Implications for Women: SOAP Note
Introduction
Women frequently present with endocrine and musculoskeletal complaints that require careful differential diagnosis and management. Conditions such as hypothyroidism, polycystic ovary syndrome (PCOS), and rheumatoid arthritis are common and may overlap in presentation, making accurate assessment critical for effective treatment. This paper presents a SOAP note for a female patient with common endocrine complaints, followed by a reflection on clinical decision-making and implications for practice.
Subjective
The patient is a 32-year-old woman presenting with fatigue, gradual weight gain, and irregular menstrual cycles over the last six months. She reports feeling unusually tired throughout the day, with energy lowest in the evenings. Despite no significant changes to diet or exercise, she has gained 12 pounds. Menstrual cycles occur every 40–60 days rather than her usual 28-day pattern. She also reports constipation, dry skin, cold intolerance, and hair thinning. Joint stiffness is present in the knees and elbows, particularly in the mornings, lasting approximately 20 minutes.
Her past medical history is unremarkable for diabetes, thyroid disease, or autoimmune disorders. She occasionally uses ibuprofen for joint discomfort. No known drug allergies. Family history is significant for maternal hypothyroidism and paternal type 2 diabetes. She does not smoke, consumes alcohol rarely, and maintains a generally balanced diet, though exercise has decreased due to fatigue.
Objective
On examination, the patient appears overweight and fatigued. Vital signs are: blood pressure 122/78 mmHg, heart rate 62 bpm, temperature 97.0°F, respiratory rate 16 breaths/min, BMI 30.1. Physical examination reveals dry, cool skin, thinning hair, and mild thyroid enlargement without nodules. Musculoskeletal examination shows mild stiffness in bilateral knees and elbows, but no swelling or erythema. Neurological assessment demonstrates slightly delayed reflexes.
Laboratory tests were ordered, including TSH, free T4, thyroid antibodies, complete blood count (CBC), comprehensive metabolic panel (CMP), fasting glucose, and HbA1c.
Assessment
Differential Diagnoses:
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Hypothyroidism – Supported by symptoms of fatigue, weight gain, cold intolerance, menstrual irregularities, dry skin, family history of thyroid disease, and thyroid enlargement.
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Polycystic Ovary Syndrome (PCOS) – Considered due to irregular menstruation and weight gain, though androgenic symptoms (acne, hirsutism) are not present.
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Rheumatoid Arthritis (RA) – Considered due to morning stiffness, but lack of significant joint swelling or prolonged stiffness reduces likelihood.
Primary Diagnosis: Hypothyroidism is most consistent with the clinical presentation and family history.
Plan
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Diagnostics: Confirm diagnosis with TSH, Free T4, and thyroid peroxidase antibody levels. Consider pelvic ultrasound and hormone panel if PCOS remains a concern.
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Pharmacologic Management: Initiate Levothyroxine 50 mcg PO daily, adjusting dose based on follow-up TSH levels.
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Non-Pharmacologic Management: Encourage increased physical activity as tolerated, a balanced diet, stress management strategies, and adequate sleep.
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Alternative Therapies: Yoga, mindfulness meditation, and acupuncture may support symptom management, particularly for fatigue and stress.
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Follow-Up: Reassess TSH in 6–8 weeks; follow-up in 2 months to evaluate treatment response and adjust dosing.
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Patient Education: Discuss the chronic nature of hypothyroidism, the importance of medication adherence, lifestyle modifications, and monitoring for changes in symptoms.
Reflection Notes
In future similar evaluations, I would ask more targeted questions regarding reproductive health, mood, and cognitive symptoms, as hypothyroidism can affect these domains significantly. I would also screen earlier for PCOS and metabolic syndrome, given the overlap in presentation and risk factors. This case underscores the importance of integrating patient history, family history, and physical assessment with evidence-based guidelines. Class readings on women’s primary care highlight the role of comprehensive screening and patient-centered education in managing chronic endocrine disorders, which directly informed my clinical reasoning in this case.
References
Centers for Disease Control and Prevention. (2012). Women’s health. http://www.cdc.gov/women/
National Institutes of Health. (2012). Office of Research on Women’s Health (ORWH). http://orwh.od.nih.gov/
Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.). Jones and Bartlett Publishers.
Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & women’s health (4th ed.). Jones & Bartlett Publishers.
U.S. Department of Health and Human Services. (2012). Womenshealth.gov. http://www.womenshealth.gov/
