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.
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
Based on your assigned case study, post a Focused SOAP NOTE with the following:
• 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 first priority in conducting your assessment.
• Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.
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-SAMPLE ANSWER-
Focused SOAP Note:
Subjective: The patient is a 58-year-old African American female who presents with the complaint of brown discharge for several days last week.
Objective: Vital signs are within normal limits. Physical exam reveals a soft, obese abdomen with positive bowel sounds. A brown discharge is noted on speculum exam, with brown blood coming from the cervical os. No cervical motion tenderness is noted. The uterus and adnexa are unable to be assessed due to the patient’s body habitus.
Assessment:
Differential diagnosis:
Endometrial atrophy – atrophic changes were noted on the patient’s last pap and her medical history is significant for being postmenopausal.
Endometrial hyperplasia – postmenopausal bleeding is a common symptom.
Endometrial cancer – a possibility due to the patient’s age and the presence of postmenopausal bleeding.
The most important diagnosis is endometrial cancer as it is a potential life-threatening condition. The first priority in conducting the assessment would be to evaluate the patient’s risk factors and to perform diagnostic tests to rule out or confirm the diagnosis.
Recommendations:
Transvaginal ultrasound- to evaluate the endometrial thickness, and to look for any suspicious lesions.
Endometrial biopsy- To confirm the diagnosis and to evaluate the tissue for malignancy.
Hysterectomy- If cancer is confirmed, hysterectomy is the recommended treatment to remove the tumor.
Follow-up with oncologist- If cancer is confirmed, the patient will need to be followed up by an oncologist for further treatment options such as radiation or chemotherapy.
The patient’s age and the presence of postmenopausal bleeding are considered as red flag symptoms, so it is important to rule out or confirm the diagnosis of endometrial cancer, as it is a potential life-threatening condition. The diagnostic tests and treatment options recommended are standard of care for postmenopausal bleeding and are in line with current clinical practice guidelines.
