Case Study: Postmenopausal Bleeding
Instructions
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 G0, 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
Episodic/Focused SOAP Note Template
Solution
Episodic/Focused SOAP Note
Patient Information:
Initials T. S., Age-58, Sex- Female, Race- African-American
S.
CC (chief complaint): The patient has been experiencing a brown discharge for the past several days of the week.
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HPI:
Location: Vaginal
Onset: Several days ago
Character: N/A
Associated signs and symptoms: N/A
Timing: Most of the time
Exacerbating/relieving factors: N/A
Severity: 7/10 scale
Current Medications: She takes glipizide and metformin for type 2 diabetes.
Allergies: No known food or drug allergies.
PMHx: The patient is up to date with her vaccinations as well as medical examinations. She had a colonoscopy 1 year ago and has a normal pap history with her last pap smear being 2 years ago.
Soc & Substance Hx: The patient is a retired social worker who sought early retirement to work on her health. Her major hobbies include spending time with friends and family. She has a history of taking social alcohol in her thirties but stopped. She denies any history of tobacco use. She has a strong support system from siblings who live in neighboring towns as well as from her extended family members living in the neighborhood.
Fam Hx: Miss T’s mother is alive but battling type 2 diabetes too. Her father succumbed to natural causes of death. Her maternal grandmother succumbed to diabetes-related complications.
Surgical Hx: No prior surgical procedures.
Mental Hx: She has no history of mental illnesses like depression or anxiety. Diagnosis and treatment. No history of self-harm practices or suicidal ideation.
Violence Hx: Has no concerns about her safety. She lives in a safe neighborhood where the community members live like one big family.
Reproductive Hx: She has never been able to get pregnant. Not sexually active.
ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning on urination.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Has never been pregnant. Brown vaginal discharge for the past days last week
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vitals: Temperature 98.1, BP 140/88, Pulse 82, Respirations 12, Height 5’6″, weight 272 ilbs (BMI 43.90)
Reproductive: Brown vaginal discharge
Diagnostic results:
Ultrasound
Biopsy
Hysteroscopy
Pelvic exam
Urinalysis
Acid balance test
A.
Differential Diagnoses
Vaginal atrophy
Vaginal atrophy refers to a condition where the vaginal epithelium thins resulting in a decreased cervical secretion (Naumova & Castelo-Branco, 2018). The condition is largely associated with decreased estrogen levels among postmenopausal women. It is vital to note that as the amount of estrogen production in the body decreases, vaginal secretions diminish and the genitourinary tissues become atrophic. Patients that have vaginal atrophy present with symptoms that include vaginal bleeding, vaginal dryness, burning, irritation, and post-coital bleeding.
Yeast infection
Yeast infection is the second differential diagnosis for the patient. The patient’s medical history shows that she has ‘somewhat’ controlled type 2 diabetes. This is an indication that the blood sugars are not effectively controlled. Individuals with poorly controlled type 2 diabetes are vulnerable to getting yeast infections due to immune damage.
Several factors including a drop in the T-lymphocyte counts, a rise in the death of leukocytes, a reduced action of neutrophils, and the reduction in the release of cytokines are aggravated due to the hyperglycemic environment among diabetic patients (Mohammed et al., 2021). An increase in the blood sugars is likely to result in an overgrowth of yeast, especially in the vaginal area. In response, the body may develop a yeast infection whose of clinical manifestation includes a colored discharge that may seem like spotting.
Endometrial hyperplasia
Endometrial hyperplasia is the third differential diagnosis for the patient. Endometrial hyperplasia refers to a condition of the female reproductive system where the lining of the uterus usually becomes thick due to having many cells (Sanderson et al., 2017). Women that develop the condition tend to produce too much estrogen as compared to progesterone. Women who have endometrial hyperplasia make barely any progesterone resulting in the non-shedding of the endometrial lining.
Instead, the lining continues to grow and become thick. Some of the clinical manifestations of the condition include vaginal bleeding and spotting. The risk factors for developing endometrial hyperplasia include being over the age of thirty-five years, being in the post-menopausal stage, and having diabetes mellitus. The patient passes the above criteria which justifies the choice for differential diagnosis.
Vaginal atrophy can be managed in several ways with the first recommendation being the use of vaginal moisturizers. They have a long-lasting effect and moisturize the vaginal mucosa as well as by lowering the Ph. Hormonal therapy replacement in second treatment for vaginal atrophy.
It entails preparations that include estradiol and conjugated estrogens. The hormonal therapy is available in various forms such as vaginal cream at a dosage of 0.5 to 1 grams one to three times a week, vaginal tablets once or twice a week. Vaginal capsules one or two times a week, a vaginal ring which should be inserted for 90 days, and oral at a dosage of 60 mg daily.
Vaginal yeast infection treatment depends on the severity as well as frequency. If the patient’s diagnosis is mild, she could be put on short-course vaginal therapy. The medications are available as creams, tablets, suppositories, and ointments. They include miconazole and terconazole. There is also single-dose oral medication fluconazole.
Endometrial hyperplasia is managed using different methods for example hysterectomy that involves the removal of the uterus. Other less invasive methods include the use of progestin treatments like oral progesterone therapy such as norethindrone, and Megace as well as progesterone hormonal intrauterine device and injection.
It would be necessary to educate the patient concerning her health risks, the effects of the medications that she is taking, and most importantly her role in ensuring that she experiences positive health outcomes. It would also be vital to tell the patient how uncontrolled diabetes could result in disease complications, a high burden of disease, and a low quality of life.
Reflection
After having an in-depth consultation with the patient, she demonstrated having understood the importance of adhering to the treatment plan and regular follow-up visits. The patient similarly understood that her current diagnosis of type 2 diabetes requires that she incorporates both pharmacological interventions with lifestyle modifications to achieve optimal health outcomes.
Her profile indicates that her diabetes is ‘somewhat’ controlled an indication that she needs to put more effort to control her health outcomes to minimize instances of complications or adverse events. It is also vital to note that the patient’s BMI is high which could be associated with her diabetes medication that results in weight gain. She, therefore, needs to participate in physical activity and change her eating patterns to regulate weight gain.
References
Mohammed, L., Jha, G., Malasevskaia, I., Goud, H. K., & Hassan, A. (2021). The Interplay Between Sugar and Yeast Infections: Do Diabetics Have a Greater Predisposition to Develop Oral and Vulvovaginal Candidiasis?. Cureus, 13(2).
Naumova, I., & Castelo-Branco, C. (2018). Current treatment options for postmenopausal vaginal atrophy. International journal of women’s health, 10, 387–395. https://doi.org/10.2147/IJWH.S158913
Sanderson, P. A., Critchley, H. O., Williams, A. R., Arends, M. J., & Saunders, P. T. (2017). New concepts for an old problem: the diagnosis of endometrial hyperplasia. Human reproduction update, 23(2), 232–254. https://doi.org/10.1093/humupd/dmw042