Case Study Of Postmenopausal Bleeding Assignment

Case Study Of Postmenopausal Bleeding Assignment

CASE STUDY: Case Study 1
Case Study: Postmenopausal Bleeding
Thelma Smith is a 58-year-old African American female who presents to the office with the complaint of brown discharge for several days last week. Her medical history is remarkable for type 2 diabetes somewhat controlled with glipizide and metformin (last A1C 7.5). She is a G0P0, having never been able to get pregnant. She is up to date with mammograms and has had a colonoscopy 1 year ago, all normal. Her pap history is normal with her last pap 2 years ago reported an NILM HPV negative, atrophic changes, no endocervical cells noted.

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Vital signs temperature 98.1 BP 140/88, pulse 82, respirations 12. She is 5’6” and 272 lbs. (BMI 43.90). Focused exam:
• Abdomen: soft, obese, + BS
• VVBSU: brown discharge noted,
• Cervix: brown blood noted coming from os, no cervical motion tenderness
• Uterus: unable to assess due to body habitus
• Adnexa: unable to assess due to body habitus
POST A Focused SOAP NOTE only and describe your case study.
Provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
Define what you believe is the most important diagnosis. Be sure to include the priority in conducting your assessment.
Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.
Also, share with your colleagues your experiences as well as what you learned from these experiences.
Note: Possibly use your “FNP or AGPCNP Skills and Procedures Self-Assessment” in your practicum experience to guide your case study selection.
Review the Learning Resources for this week and specifically review the clinical guideline resources specific to your proposed case study.
Use the Focused SOAP Note Template found in the Learning Resources to support your discussion. Complete a Focused SOAP note and critically analyze this and focus your attention on the diagnostic tests.

Patient Information:

Initials: T.S.,   Age: 58 years old   Gender: Female;   Race: African American (AA)

SUBJECTIVE

CC: Case Study: “I have come due to postmenopausal bleeding.”

HPI: Client, T. S is a 58yo AA female. Upon visiting the office, she complains of brown discharge. The client reports that the discharge has persisted for several days last week. She did not report any relieving or aggravating factors. The client also discloses a history of type 2 diabetes, which she controls with glipizide and metformin. Her last A1C was 7.5.

Current Medications:

1. Glipizide 5 mg orally once/day: Taken for blood glucose maintenance
2. Metformin 500 mg orally twice per day: Taken to control blood glucose level.

Allergies: Denies medication, food, or environmental allergies.

PMHx: Denies past major illnesses or surgeries.

Soc & Substance Hx: No information provided.

Fam Hx: No details

Surgical Hx: Denies previous surgical procedures.

Mental Hx: Denies history of mental health disorder.

Violence Hx: Denies violence history.

Reproductive Hx: T.S is a G0P0. She denies never being able to conceive. The client had a colonoscopy in the past year and her mammograms are up to date and all results were normal. The client further added that her last pap test was 2 years ago with a normal pap history. Her NILM HPV was negative with no endocervical cells noted.

ROS

GENERAL: The client denies weight changes, fatigue, or weakness.

HEENT:

Eyes: She denies yellow sclerae or blurred vision.

     Ears: Denies hearing loss, ear pain, or drainage from the ears.

     Nose: Denies nasal congestion or runny nose

Throat: Denies sore throat.

SKIN: Denies skin rashes, swellings, or discoloration.

CARDIOVASCULAR: Denies chest pain.

RESPIRATORY: Denies cough, shortness of breath, difficulty breathing, or sputum production.

GASTROINTESTINAL: Denies anorexia, abdominal pain, or constipation.

NEUROLOGICAL: Denies problems with walking or standing for a long duration.

MUSCULOSKELETAL: Denies unsteady gait or muscle problems.

HEMATOLOGIC: Denies bleeding or anemia.

LYMPHATICS: Denies swollen or inflamed nodes.

PSYCHIATRIC: Denies being anxious, suicidal thoughts, suicidal attempts, or being easily agitated.

ENDOCRINOLOGIC: Denies excessive sweating.

GENITOURINARY/REPRODUCTIVE: Reports brown vaginal discharge

ALLERGIES: Denies food, drug, or environmental allergy.

OBJECTIVE

Physical exam:

General: The client is a 58yo AA female who looks younger than her age. She is attentive and asks questions during the clinical interview. She is presentable, well-groomed, and appropriately dressed for today’s weather and time of the year. Her judgment, insight, and effect are good.  She does not seem to be in acute distress and depicts a strong thought process. She is alert and oriented to events, persons, places, and events.

Vitals signs: T 98.1    BP 140/88, respirations 12, pulse 82, W 272 lbs H 5’6” BMI score43.90

HEENT: No scars seen on the head. Equally round pupils with light sensitivity. Tympanic membranes with no redness. No nasal drainage. Clear nasal turbinates with no obstruction. No anterior or posterior cervical nodes.

Abdomen: Obese, soft, + BS.

VVBSU:  brown discharge is seen.

Cervix: No cervical motion tenderness noted. Brown blood coming from os seen.

Uterus: Not assessed due to body habitus.

Adnexa: Not assessed due to body habitus.

Diagnostic results:

Microscopic examination: It is ordered to detect the presence of leukocytes or trichomonas.

Swab: To detect the presence of hyphae or budding yeast.

pH: To assess pH range in the vagina.

Whiff test: To detect fishy odor present in bacterial vaginosis

Gram stain: To detect yeast or bacterial floral

ASSESSMENT

Primary Diagnosis: Perimenopause

Perimenopause is the primary diagnosis for this client. This condition is characterized by the menopause stage, which is characterized by several changes noted as the body is adjusting to the transition. During perimenopause, the levels of estrogen fluctuate resulting in hormonal imbalance, which disrupts the menstrual cycle (Allshouse et al., 2018). A brown discharge is seen resulting from the disruption of the normal menstrual cycle. A person might experience other symptoms, including vaginal dryness and pain, hot flashes, night sweats, and mood swings.

Differential Diagnoses

The potential differential diagnosis for this client are as follows

1. Pelvic inflammatory disease (PID)
2. Endometriosis

• Sexually transmitted infections (STIs)

Pelvic inflammatory disease (PID) is the first differential diagnosis for this client. This condition is an infection of the uterus and the cervix, which sometimes causes a brown discharge. It results from untreated STIs, including gonorrhea or chlamydia. Other symptoms include lower abdomen and pelvis, fever, pain during sex, heavy discharge with a foul odor, and painful urination. Although the client reported brown discharge, this condition was ruled out due to the absence of other vital symptoms. Endometriosis is the second potential diagnosis for this client. This condition is characterized by brown discharge, irregular bleeding, and heavy periods. Despite reporting brown discharge, this condition is ruled out due to the absence of significant symptoms such as irregular bleed and heavy periods. Lastly, the client might have STIs, including chlamydia or gonorrhea. These conditions are characterized by spotting, brown discharge, vaginal discharge with a foul smell, a burning sensation when urinating, and pain during sex. This condition is a potential diagnosis since the client reported brown discharge. However, STIs are ruled out due to the absence of other significant symptoms.

Plan.

Results of various diagnostic studies, including microscopic examination, pH test, swab test, whiff test, and gram test will be documented to guide the development of the best treatment plan for this client. Additionally, the client will be referred to a gynecologist for a culture test for further examination of the brown discharge to detect any microorganism that might be causing the symptoms. Upon treating this client again, I would gather more reproductive history such as previous STIs or if the client is sexually active to guide in ruling out STIs. The health promotion and disease prevention target the client’s BMI score (43.90), which indicates that she is obese. Therefore, the client should be educated on how to adjust her lifestyle, including taking a diet with fewer calories and high fiber and increasing physical activities to lose and maintain a healthy weight. By maintaining a healthy weight, the client’s obesity will be reversed. According to Fruh et al. (2017), obesity is a significant factor, contributing to other preventable chronic illnesses. Additionally, being an African American, the client is at a higher risk of developing T2DM (Caballero, 2018). Hence, reversing the client’s obesity will reduce the risk of developing other health complications, including cardiovascular diseases, diabetes 2 Mellitus, and hypertension.

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References

Allshouse, A., Pavlovic, J., & Santoro, N. (2018). Menstrual cycle hormone changes associated with reproductive aging and how they may relate to symptoms. Obstetrics and Gynecology Clinics, 45(4), 613-628.

Caballero, A. E. (2018). The “A to Z” of managing type 2 diabetes in culturally diverse populations. Frontiers in endocrinology, 9, 479. https://doi.org/10.3389/fendo.2018.00479

Fruh, S. M. (2017). Obesity: Risk factors, complications, and strategies for sustainable long‐term weight management. Journal of the American Association of Nurse Practitioners, 29(S1), S3-S14. Doi: 10.1002/2327-6924.12510 Case Study Of Postmenopausal Bleeding Assignment