Week 4: Case Study 1- Episodic/Focused SOAP Note
Initials: T.S Age: 58 Sex: Female Race: African American
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CC (chief complaint): “brown discharge to pink spotting”
HPI: T.S., a 58-year-old African American woman, comes into the clinic complaining of brown discharge to pink spotting for many days last week. The patient’s medical record indicates a noteworthy medical history of type 2 diabetes, which has been partially managed through the use of glipizide and metformin, as evidenced by a recent A1C reading of 7.5. She has a nulliparous obstetric history, indicating that she has never experienced a pregnancy. The patient is current with regards to mammograms and underwent a colonoscopy one year prior, with results indicating no abnormalities. The patient’s pap smear history is within normal limits, with her most recent pap smear conducted two years ago indicating a negative for intraepithelial lesion or malignancy (NILM) result. The results indicate a lack of HPV presence, the presence of atrophic changes, and the absence of endocervical cells.
Onset: last week
Character: brown discharge to pink spotting
Associated signs and symptoms: none
Exacerbating/relieving factors: none
Severity: 6/10 pain scale
Current Medications: Glipizide 5 mg once a day and metformin 500 mg twice daily
Allergies:No known sensitivities to substances, foods, or environments.
Past Medical History: type 2 diabetes which is well managed with medication
Immunizations: Vaccination records are current.
Soc & Substance Hx: The patient is married but has never given birth and has no children. She shares a two-story, three-bedroom single-family home with her hubby. prohibits using tobacco, using e-cigarettes, vaping, or being around others who do. denies engaging in illicit or recreational drug use. denies having a drink. She says she is now a banker. She professes to be a devout Christian and puts a lot of importance on her spiritual health. She says she has a huge network of family, friends, and churchgoers. She eats three meals a day and says she tries her hardest. She naps for six to eight hours. She usually works out by taking the dog for a walk in the evening.
Fam Hx: Her father has diabetes and is 83 years old. Two years ago, her mother’s cervical cancer took her life.
Mental Hx:denies sadness or anxiety. denies having ever used self-harm or had suicidal or homicidal thoughts.
Violence Hx:denies any safety worries or concerns
Reproductive Hx: GYN History: LMP eight years ago; most recent Pap test was two years ago; results were WNL; one partner; and no use of birth control; straight. OB History: Gravida: 0 Para: 0
GENERAL: The patient seemed healthy, and active, and denied having gained or lost weight.
HEENT: Eyes: denies any loss of vision, double vision, impaired vision, or yellow sclera. Denies hearing loss, sniffles, congested nose, runny nose, or hoarseness.
SKIN: denies having a rash or irritation.
CARDIOVASCULAR: denies feeling pressure, pain, or discomfort in the chest. No edema or palpitations.
RESPIRATORY: denies having a cough, sputum, or shortness of breath.
GASTROINTESTINAL: denies having anorexia, motion sickness, or diarrhea. neither blood nor stomach discomfort.
NEUROLOGICAL: denies experiencing headaches, vertigo, syncope, paralysis, ataxia, or tingling in the extremities. No modification to bladder or bowel control.
MUSCULOSKELETAL: denies experiencing stiffness, joint discomfort, back pain, or muscular pain.
HEMATOLOGIC: denies bruising, bleeding, or anemia.
LYMPHATICS: denies having larger nodes. denies having had a splenectomy.
PSYCHIATRIC: denies having a history of anxiety or depression.
ENDOCRINOLOGIC: reports a type 2 diabetes history. denies having a cold or heat sensitivity or sweating. No polydipsia or polyuria.
GENITOURINARY/REPRODUCTIVE: complaints of brown discharge to pink spots last week, lasting for many days. LMP eight years back, last Pap test two years ago, resulting in WNL, one partner, no birth control use, heterosexual. OB History: Gravida: 0 Para: 0
ALLERGIES: denies having ever had rhinitis, hives, asthma, or eczema.
Vital signs: Temperature: 98.1°F, blood pressure: 140/88, pulse: 82, and respirations: 12. She is 272 pounds and 5’6″. (BMI 43.90).
General: focused and awake. seemed to be well-groomed. The patient does not seem to be experiencing any immediate discomfort.
Abdomen: soft, overweight, and bowel sound-positive
VVBSU: observed brown discharge,
Cervix: No cervical motion pain and brown blood were seen originating from the os
Uterus: being unable to evaluate owing to the physical habit
Adnexa: owing to bodily habit, impossible to evaluate
Diagnostic results: A1C last 7.5. Her Pap history is normal, and her most recent Pap revealed a NILM two years ago. Atrophic alterations, no endocervical cells, and HPV negative.
Primary and Differential Diagnoses
- Endometrial or Vaginal Atrophy: Brown spotting after menopause, as seen by the patient, is often an indication that blood has mixed with the discharge. According to studies, postmenopausal women often have vaginal atrophy, which may cause brown spotting and itching (Nappi et al., 2020).
- Endometrial polyps: Brown discharge seen before and after menstruation is another sign of polyps (Tanos, 2019). Painless polyps do not exist.
- UTI: Diabetic patients, like the one mentioned above, often get UTIs. In addition to the acute UTI symptoms, persistent UTIs may result in spotting, blood in the urine, or discharge (Wasserman & Rubin, 2023).
Primary diagnosis: Endometrial or Vaginal Atrophy
- What additional symptoms do you manifest besides the transition from pink discharge to brown spotting? This inquiry will facilitate the acquisition of additional data to bolster the primary diagnosis. Elia et al. (2019) have identified several symptoms that are associated with the condition, including vaginal dryness, itchiness, burning during urination, and recurrent urinary tract infections.
- What was the date of your most recent menstrual cycle? The inquiry in question is intended to ascertain whether the symptoms exhibited by the patient are attributable to menopause, as posited by Elia et al. (2019).
- Have you engaged in sexual activity recently? This inquiry will aid in ascertaining whether the individual’s symptoms are attributable to a sexually transmitted infection/disease.
The lining of the patient’s vagina becomes drier and thinner in vaginal atrophy. To corroborate this diagnosis, the inquiries will concentrate on symptoms like itchiness, burning, and discomfort during sex, among others (Nappi et al., 2020). Urinary tract issues such as urinary incontinence and UTIs are also a part of this illness.
Diagnostic tests: A Pap test, ultrasound, urine sample, vaginal pH (acid test), and testing for vaginal infection will all be required to establish the main diagnosis and exclude the differentials (Nappi et al., 2019).
Treatment options: Only dehydroepiandrosterone (DHEA) and estrogen therapy are hormone treatments for vaginal atrophy (Pinkerton, 2021).
Health Promotion: Regular sexual activity improves vaginal tissue blood flow, which helps prevent vaginal atrophy (Nappi et al., 2019).
Patient Education: admonish the patient to stay away from vaginal irritants including douching, dye, shampoo, and cologne (Nappi et al., 2019).
Referrals: The patient needs to see a gynecologist for further assessment and treatment.
Follow-up: After two weeks, the patient must return to the clinic for an assessment of the effectiveness of the therapy.
Reflection: The material presented for the assigned case study is rather scant, supporting the main vaginal atrophy diagnosis. Brown spotting is a frequent symptom of menopause and may be brought on by several medical issues. However, DHEA is the most effective kind of therapy if the patient’s vaginal atrophy is proven (Pinkerton, 2021). To improve the patient’s general health and well-being, it is also important to encourage her to consume a good diet and exercise often. One of the key preventative methods for vaginal atrophy has also been suggested: regular sexual activity.
Elia, D., Gambacciani, M., Berreni, N., Bohbot, J. M., Druckmann, R., Geoffrion, H., Haab, F., Heiss, N., Rygaloff, N., & Russo, E. (2019). Genitourinary syndrome of menopause (GSM) and laser VEL: a review. Hormone Molecular Biology and Clinical Investigation, 0(0). https://doi.org/10.1515/hmbci-2019-0024
Nappi, R. E., Di Carlo, C., Cucinella, L., & Gambacciani, M. (2020). Viewing symptoms associated with Vulvovaginal Atrophy (VVA)/Genitourinary syndrome of menopause (GSM) through the estro-androgenic lens – Cluster analysis of a web-based Italian survey among women over 40. Maturitas, 140, 72–79. https://doi.org/10.1016/j.maturitas.2020.06.018
Nappi, R. E., Martini, E., Cucinella, L., Martella, S., Tiranini, L., Inzoli, A., Brambilla, E., Bosoni, D., Cassani, C., & Gardella, B. (2019). Addressing Vulvovaginal Atrophy (VVA)/Genitourinary Syndrome of Menopause (GSM) for Healthy Aging in Women. Frontiers in Endocrinology, 10. https://doi.org/10.3389/fendo.2019.00561
Pinkerton, J. V. (2021). Selective Estrogen Receptor Modulators in Gynecology Practice. Clinical Obstetrics & Gynecology, 64(4), 803–812. https://doi.org/10.1097/grf.0000000000000647
Tanos, V. (2019). Management of endometrial polyps. Women Health Care and Issues, 2(1), 01–07. https://doi.org/10.31579/2642-9756/004
Wasserman, M. C., & Rubin, R. S. (2023). Urologic view in the management of genitourinary syndrome of menopause. Climacteric, 1–7. https://doi.org/10.1080/13697137.2023.2202811
I enjoyed reading your discussion post. I am intrigued by the information that you have presented, it captured my interest. I share your sentiments where you mentioned that a pap smear, ultrasound, urine sample, and testing for vaginal infection will be required to establish a diagnosis of endometrial or vaginal atrophy. In addition to the diagnostic investigations, I would also recommend endometrial biopsy and hysteroscopy. Postmenopausal women are at risk for endometrial malignancies and present with post-menopausal bleeding.
The current recommendations from the American College of Obstetricians and Gynecologists postulated that sampling of endometrial tissue should be the first-line procedure in the management of abnormal uterine bleeding in women over 45 years old. Histopathological assessment of the endometrium is the gold standard for diagnosis of endometrial pathologies. Endometrial sampling can be performed as an outpatient or inpatient procedure (Husain et al., 2021).
Atrophic endometrium is one of the most common causes of abnormal uterine bleeding in women over 55 years old. This is due to hypoestrogenism which occurs in the menopausal period. Dilation and curettage are performed in order to obtain endometrial samples for pathological testing. Patients with atrophy of the endometrium will have a diagnostic procedure like an endometrial biopsy performed to confirm this diagnosis. Research study has shown that approximately 90% of patients who are postmenopausal, asymptomatic, and have an endometrial thickness that is less than 7 mm was observed to have a trophic endometrium upon being biopsied (Husain et al., 2021).
In the past, an evaluation of intrauterine pathologies was performed with blind dilation and curettage of the uterus. This usually results in misleading diagnoses. Over the last decade, this procedure has been replaced by hysteroscopy. Currently, hysteroscopy is the gold standard procedure to diagnose and manage intrauterine pathologies in both premenopausal and postmenopausal women. Hysteroscopy is the only diagnostic procedure that facilitates direct visualization of the endometrial cavity. Owing to technological advancement, targeted endometrial biopsies are performed under direct visualization. Treatment of endometrial pathologies may also be performed without the need for dilation and curettage under anesthesia (Fagioli et al., 2020).
To complete a comprehensive assessment, all women require appropriate diagnostic investigations that are capable to diagnose gynecological health issues. Examples of appropriate diagnostic investigations are pelvic ultrasound, endometrial biopsies, and hysteroscopy.
Fagioli, R., Vitagliano, A., Carugno, J., Castellano, G., De Angelis, M. C., & Di Spiezio Sardo, A. (2020). Hysteroscopy in postmenopause: From diagnosis to the management of intrauterine pathologies. Climacteric, 23(4), 360–368. https://doi.org/10.1080/13697137.2020.1754387
Husain, S., Al Hammad, R. S., Alduhaysh, A. K., AlBatly, M. M., & Alrikabi, A. (2021). A pathological spectrum of endometrial biopsies in Saudi women with abnormal uterine bleeding. Saudi Medical Journal, 42(3), 270–279. https://doi.org/10.15537/smj.2021.42.3.20200814
Thank you for your response, I found it very insightful. I would like to provide some feedback on the diagnostic tests for the patient described in the case study. In your post you suggested several diagnostic tests, including a Pap test, ultrasound, urine sample, vaginal pH (acid test), and testing for vaginal infection. However, given the patient’s chief complaint of “brown discharge to pink spotting” and her medical history, I would approach the diagnostic workup slightly differently. Based on the patient’s symptoms and medical history, with vaginal atrophy as the primary diagnosis, I would prioritize such diagnostic tests as endometrial biopsy, transvaginal ultrasound, and vaginal pH and microscopy. Since postmenopausal bleeding can be associated with endometrial pathology, it would be prudent to perform an endometrial biopsy to rule out endometrial hyperplasia or malignancy. This test would help confirm or exclude other potential causes of the patient’s symptoms, such as endometrial polyps (Louie & Vegunta, 2022). By examining the tissue sample under a microscope, any atypical or malignant changes in the endometrial cells can be detected.
Transvaginal ultrasound can provide valuable information about the thickness of the endometrial lining and detect any structural abnormalities, such as polyps or masses. It can help to further evaluate the endometrium and assess the overall condition of the pelvic organs, including the ovaries. Transvaginal ultrasound is a non-invasive procedure that uses sound waves to generate images, allowing healthcare providers to visualize the pelvic structures. The clinical approach to dealing with postmenopausal bleeding requires a timely and efficient evaluation to rule out or diagnose endometrial carcinoma and endometrial intraepithelial neoplasia (Louie & Vegunta, 2022). Initially, transvaginal ultrasonography can be used as a sufficient method for evaluating postmenopausal bleeding. If the ultrasound images show a thin endometrial echo, the likelihood of endometrial cancer is very low. Therefore, transvaginal ultrasonography can be a reasonable first step in evaluating postmenopausal women who experience bleeding for the first time. If an endometrial sample taken blindly does not indicate endometrial hyperplasia or malignancy, further testing such as hysteroscopy with dilation and curettage should be considered for women with persistent or recurring bleeding.
In the case of incidentally discovering an endometrial measurement greater than 4 mm in a postmenopausal patient who is not experiencing any bleeding, it may not be necessary to routinely conduct an evaluation (Black, 2023). However, it is important to assess the situation individually based on the patient’s characteristics and risk factors. It’s worth noting that transvaginal ultrasonography is not an appropriate screening tool for endometrial cancer in postmenopausal women who do not have any bleeding symptoms.
While testing for vaginal infections is important, the pH measurement and microscopic examination of vaginal discharge can help differentiate between infectious causes and atrophic vaginitis. A high vaginal pH (>4.5) is commonly seen in infections like bacterial vaginosis, whereas a pH within the normal range but with the absence of significant inflammatory cells supports the diagnosis of atrophic vaginitis (Black, 2023). Microscopic examination can also identify the presence of clue cells which indicate bacterial vaginosis, or yeast cells which signify vaginal candidiasis. By focusing on these diagnostic tests, we can more specifically address the primary and differential diagnoses in a targeted manner. The endometrial biopsy would provide crucial information to rule out endometrial pathology, while the transvaginal ultrasound and vaginal pH and microscopy would aid in the evaluation of vaginal atrophy and potential infections. It is important to individualize the diagnostic workup based on the patient’s unique presentation and medical history. Consulting with a gynecologist or specialist would also be beneficial in determining the most appropriate diagnostic tests and confirming the diagnosis.
Black, D. (2023). Diagnosis and medical management of abnormal premenopausal and postmenopausal bleeding. Climacteric, 26(3), 222-228. https://doi.org/10.1080/13697137.2023.2178893
Louie, M. Y., & Vegunta, S. (2022). Abnormal uterine bleeding in perimenopausal women. Journal of Women’s Health, 31(8), 1084-1086. https://doi.org/10.1089/jwh.2022.0273