Mallory Miner

SOAP Note #3
Identification:
LP: 22 y.o Caucasian Female
Date of Visit: 02/17/17
BYU-Idaho Student Health Insurance
Subjective:
Chief Complaint: I am getting married and want a pre-martial physical.
History of Present Illness:
Pt states she is engaged to be married in April 2017. Denies any sexual
history. She was taking some birth control pills, Emoquette 0.15-30mg, to
treat acne in the fall 2016 but only took it for one month because after she
started taking them she noticed daily headaches (not migraines).
Pt states she is currently taking Accutane and seeing a dermatologist and
has a contract with them, would like lab work completed today to take to her
next appointment (lipids/triglycerides, liver function tests, and pregnancy
test) and reports she will stop acne treatment in April. Pt reports the
headaches decreased/stopped once she was off the birth control. Pt went to
the pre-martial class at BYU-Idaho and would like to start a birth control pill
today.
Past Medical History:
No seizures, no eating disorder, no heart disease, no substance abuse,
no history of abuse, no history of sexual assault or sexual abuse, no
migraine hx, no blood clot history.
Menarche: 14, periods occur monthly, flow lasts about 5-6 days,
moderate flow and minimal cramps. Pt uses tampons routinely.
Past Surgical History:
Adenoidectomy & tonsillectomy 2001.
Uvulectomy 2003.
Family History:
Mom: Anxiety, ADHD
Dad: Alive and Healthy
 Siblings: None. Pt is an only child.
Allergies:
NKDA
None.
Medication:
Accutane 20mg/day
Social History: Pt is originally from Southern California. She met her fianc at
school and is excited for her upcoming marriage. She and her fianc are both
college students attending BYU-Idaho. She lives off campus in an apartment
complex. She has a vehicle. She does not have any pets. Her major is pre-
nursing and she enjoys working out. She does not have any pets. Denies
alcohol, drug, or tobacco use.
Immunizations: Up to date. Last influenza vaccine 10/2016.

Review of Systems
General: Pt reports she is overall healthy. Denies fevers, chills, sweats,
anorexia, fatigue, malaise, weight loss.
Eyes: Pt does not wear corrective lenses. Denies blurring, diplopia, irritation,
discharge, vision loss, eye pain, photophobia.
Ears/Nose/Throat: Denies earache, ear discharge, tinnitus, decreased
hearing, nasal congestion, nosebleeds, sore throat, hoarseness, dysphagia.
Cardiovascular: Denies chest pains, palpitations, syncope, dyspnea on
exertion, orthopnea, PND, peripheral edema.
Respiratory: Denies shortness of breath, cough, dyspnea, excessive sputum,
hemoptysis, wheezing.
Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, change in
bowel habits, abdominal pain, melena, hematochezia, jaundice.
Genitourinary: Denies vaginal discharge, incontinence, dysuria, hematuria,
urinary frequency, amenorrhea, menorrhagia, abnormal vaginal bleeding,
pelvic pain.
Musculoskeletal: Denies back pain, joint pain, joint swelling, muscle cramps,
muscle weakness, stiffness, arthritis.
Skin: Acne, currently tx with Accutane. Denies rash, itching, dryness,
suspicious lesions.
Neurologic: Denies transient paralysis, weakness, paresthesias, seizures,
syncope, tremors, vertigo.
Psychiatric: Denies depression, anxiety, memory loss, mental disturbance,
suicidal ideation, hallucinations, paranoia.
Endocrine: Denies cold intolerance, heat intolerance, polydipsia, polyphagia,
polyuria, weight change.
Heme/Lymphatic: Denies abnormal bruising, bleeding, enlarged lymph
nodes.
Allergic/Immunologic: Denies urticaria, hay fever, persistent infections, HIV
exposure.
Reproductive: Denies any sexual history.
Vital Signs:
Height: 65in.Weight: 135.8 lbs. KG: 60.60 BMI (in-lb) 22.68 BSA 1.68
BP: 118/80 SP02 : 94 Pulse rate: 98 Temp: 98.9 tympanic Pain:0/10
Physical Exam
General appearance: well nourished, well hydrated, no acute distress.
HEENT: Head: Normocephalic. Eyes: Pupils equal, round, reactive to light and
accommodation. Ophthalmoscopic: discs sharp and flat, no a/v nicking,
hemorrhages, or exudates. External ears: no lesions or deformities.
Otoscopic: canals clear, tympanic membranes intact with good movement,
no fluid Nose: pink nasalmucosa, septum, and turbinates pink. Pharynx:
tongue pink, posterior pharynx without erythema or exudate
Neck: supple, no masses, trachea midline
Thyroid: no nodules, masses, tenderness, or enlargement.
Cardiovascular: Clear to auscultation: S1, S2, no murmur, rub, or gallop
Respiratory: Auscultation: no rales, rhonchi, or wheezes.
Gastrointestinal: Flat soft symmetric appearance, BS active x 4 quadrants.
Genitourinary/ Reproductive: External genitalia: no lesions or discharge.
Vagina: no discharge, lesions. No evidence of cystocele or rectocele. Exam
Comments: Vaginal opening check: 1 finger easily inserted
Musculoskeletal: Gait and station: steady gait. +5/5 strength bilateral UE and
LE. Full AROM.
Skin: Inspection: no rashes, lesions, or ulcerations
Neurologic: Reflexes: 2+, symmetric, no pathological reflexes
Mental Status Exam: Mood and affect: pleasant.

Assessment:
1. Encounter for General Adult Medical Exam without Abnormal Findings
(Z00.00)
2. Encounter for general counseling and advice on contraception (Z30.0)
3. Screening for lipid disorders (Z13.220)
4. Screening for pregnancy test (Z32.00)
5. Screening for unspecified for disease or disorder (Z13.9)
6. Acne vulgaris (ICD-706.1)
Differential diagnosis: for Acne
Acne Conglobata
Acne Fulminans
Acne Keloidalis Nuchae
Acneiform Eruptions
Dermatologic Manifestations of Tuberous Sclerosis
Folliculitis
Perioral Dermatitis
Rosacea
Sebaceous Hyperplasia
Syringoma

Screening:
Routine screening lab work
To rule out Pregnancy prior to starting birth control.
Plan:
1. Encounter for General Adult Medical Exam Education:
Educated patient on importance of healthy diet and regular exercise.

2. Encounter for general counseling and advice on contraception:

Pt states she will take birth control daily. Contraceptive counseling
completed. Discussed current and future contraceptive needs. Pt stated she
would like to wait at least a year before trying to get pregnant. Discussed
her personal preferences, including tolerance of side effects, and speed to
return of fertility after method cessation. Monitor for headaches since she
experienced them with her last birth control. Discussed the effect on
menstrual pattern and bleeding.
Medications: MICROGESTIN FE 1/20 1-20 MG-MCG ORAL TABS (NORETHIN
ACE-ETH ESTRAD-FE) 1 po qday #28[Tablet]
3. Screening for lipid disorders:
Test:
Lipid Panel: Cholesterol, Total (5.1)178 mg/dL 130-200
Triglyceride (5.1) 88.0 mg/dL 30.0-150.0
Direct HDL Cholesterol 43 mg/dL 40-60
LDL (Calc) (5.1) [H] 117 mg/dL 0-100
VLDL (5.1) 18 mg/dL
NON-HDL (5.1) [H] 135.00 mg/dL 0.00-130.00
Coronary Risk (5.1) [H] 4.1 Ratio 0.0-4.0
4. Screening for pregnancy test Education:
Discussed safe sexual practices. Policy to check HCG prior to starting
birth control.
Test:
HCG, Serum QL (1021)
HCG, Serum Qualitative: Negative
5. Screening for unspecified for disease or disorder:
Labs/Diagnostics:
Test: Hepatic Panel (5.1) (25)
Total Protein 6.7 g/dL 6.3-8.2
Albumin 4.1 g/dL 3.5-5.0
Total Bilirubin 0.30 mg/dL 0.20-1.30
AST (SGOT) 49 U/L 22-58
ALT (SGPT) [H] 77 U/L 9-52
Alkaline Phosphatase 57 U/L 50-145
Direct Bilirubin 0.10 mg/dL 0.00-0.40

Tests: 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 0.0-0.5
#Bas 0.0 x10 0.0-0.1

Tests: 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 >90 Normal, 60-89 Mild Renal Insufficiency, 30-59 Moderate
Insufficiency, 16-30 Severe Renal Insufficiency, <15 Renal Failure.

Tests: Direct Bilirubin (5.1) (52)

Direct Bilirubin 0.30 mg/dL 0.00-0.40

6. Acne vulgaris
Pt will continue to see dermatologist for Accutane.

Plan: Pt verbalized understanding and agrees with plan of care. F/U in 6

months or sooner if needed.
Mallory Miner, DNP Student
Follow Up: Pt was notified of lab work results.
Evidence Based-Practice: The hierarchy of evidence is used to determine the
best research. The article I chose for this SOAP note was The effect of drug
consultation center guidance on contraceptive use among women using
isotretinoin: a randomized, controlled study. I chose this article because it is
a level I on the hierarchy of evidence. Randomized control trials are the gold
standard for research.
The article talks about women of reproductive age who are treated with
isotretinoin (Accutane) are required to use two forms of contraceptives. This
is because isotretinoin (Accutane) is contraindicated in pregnancy, and if
used during pregnancy it increases the risk of spontaneous miscarriage, is
associated with retinoic acid embryopathy, including cardiac, central nervous
system (CNS), and craniofacial birth defects. The system used is iPLEDGE,
which requires prescribing physicians, pharmacists, distributors, and all
patients to register in a single database online or by phone, and verify the
results of two negative pregnancy tests and use of two forms of
contraception. A randomized, controlled study was conducted at the Drug
Consultation Center in Israel. Furthermore, in Israel only dermatologists
prescribe isotretinoin. The control group received information only during the
initial interview. The intervention group was additionally informed about the
teratogenic risk and the importance of contraceptive use in mailed written
form and by text messages sent to their cellular phones 1 month and 2
months after the initial call. Then 3 months after the first interview, follow up
calls found 75% of the study group and 54% of the control group were still
taking isotretinoin.
Some of the implications from this study are that the first step in avoiding
isotretinoin-exposed pregnancies, is that the patient understand the
information given by prescribing physicians-almost all women (96%) who
contacted the medical center claimed to have been informed about the
teratogenic effects.
Nevertheless, half of the women did not use any contraceptive, and very few
used two forms of contraception as necessary by the manufacturer and
recommended by existing prevention programs. The authors believe it is
also important to address women of reproductive age who claim they are not
sexually active. Most of the women interviewed were single, and a woman
claiming to be sexually inactive may become active during treatment, and
possibly not use a contraceptive. Therefore, abstinence was not considered
an acceptable form of contraception for women who reported being sexually
inactive.
Reflection:
I was aware of the extent of side effects and risks related to isotretinoin
(Accutane) such as spontaneous miscarriage and craniofacial birth defects.
I talked with my preceptor about Accutane and she said she would never
prescribe it because it is a medication with many adverse side effects. I
would not prescribe this medication.
I am glad that my patient understood the importance of discontinuing
Accutane in April. She wanted a full lab work up because she was taking
Accutane and her dermatologist recommended lab work to be completed.
This experience taught me the importance of making sure that my patients
are knowledgeable about the medications they are taking and the effect the
medications can have if they become pregnant.
I am also glad I was able to provide contraceptive counseling. My patient was
already aware of how to take birth control pills due to previous experience.
However, she did not have experience with the current method and I feel as
though she left satisfied with her visit.
Reference
Tsur, L., Kozer, E., & Berkovitch, M. (2008). The effect of drug consultation
center guidance on contraceptive use among women using isotretinoin: a
randomized, controlled study. Journal of Women's Health (15409996), 17(4),
579-584. doi:10.1089/jwh.2007.0623