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Case Study For Patient Complaining Of Bleeding Discussion

Case Study For Patient Complaining Of Bleeding Discussion

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Soap Note case study week 4

Patient Information:

SL, 24, Female, Caucasian

S.

CC: Bleeding after intercourse.

HPI: Susan Lang is a 24-year-old Caucasian female. She presents with bleeding after intercourse for the past six weeks. She also reports a sore throat that has been persisting for three weeks. She had a fever for a brief period, managed with Tylenol, and attributed it to allergies. Her vital signs indicate a temperature of 97.8, pulse of 68, and blood pressure of 112/64. She reports no significant medical or surgical history, takes no medications, and has no known allergies. Susan has smoked half a pack of cigarettes daily since age 14, drinks alcohol only on weekends (6-8 stiff liquor drinks)Case Study For Patient Complaining Of Bleeding Discussion, and smokes marijuana daily. Menstrual history reveals onset at age 13, occurring every 28-32 days, lasting 4-6 days, with moderate cramping, managed with Midol. She jogs 3-4 times weekly, wears seatbelts, and occasionally uses sunscreen. Physical examination shows bilateral anterior cervical adenopathy, a reddened throat, fibrocystic breast changes, bilateral nipple piercings, regular abdominal and genital exams, and a friable cervix with petechiae but without motion tenderness.

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Current Medications: Not indicated.

Allergies: None indicated.

PMHx: No significant past medical history reported.
Soc & Substance Hx:

  1. Occupation: Not provided
  2. Tobacco: Smoking half a pack per day since age 14
  • Alcohol: 6-8 hard liquor drinks on weekends
  1. Marijuana: Daily use Health Promotion: Wears seatbelts, occasional sunscreen use

Fam Hx: Non-contributory

Surgical Hx: No reported surgical procedures.

Mental Hx: No reported mental health diagnosis or treatment. No history of suicidal ideation mentioned.

Violence Hx: No reported safety concerns or history of violence.

Reproductive Hx:

  1. Menstrual History: Onset at age 13, occurring every 28-32 days, lasting 4-6 days.
  2. Contraception: Not specified
  • Sexual Practices: Postcoital bleeding reported; types of intercourse not detailed.

Additional Questions

  1. Frequency and Duration:

How often do you experience postcoital bleeding?

How long has this been occurring?

  1. Nature of Bleeding:

Can you describe the type of bleeding you’re experiencing (spotting, heavy bleeding)?

Have you noticed any changes in the color or consistency of the blood? Case Study For Patient Complaining Of Bleeding Discussion

  1. Pain Assessment:

Do you experience any pain during or after intercourse?

If yes, can you describe the nature and location of the pain?

  1. Changes in Sexual Activity:

Have there been any recent changes in your sexual activity or practices?

Are you using any new contraceptives or sexual health products?

  1. Additional Gynecological Symptoms:

Have you noticed any unusual vaginal discharge?

Do you experience pelvic pain unrelated to intercourse?

Types of Symptoms to Assess:

  1. Temporal Aspects: Assess the frequency and duration to differentiate between acute and chronic conditions.
  2. Bleeding Characteristics: Understanding the nature of bleeding provides insights into potential causes.
  3. Pain Description: Assess pain characteristics to identify possible underlying issues like trauma or inflammation.
  4. Sexual Activity Changes: Changes in sexual practices or contraceptive use may contribute to postcoital bleeding.
  5. Additional Gynecological Symptoms: Inquire about vaginal discharge and pelvic pain to identify concurrent gynaecological issues. Case Study For Patient Complaining Of Bleeding Discussion

ROS:

GENERAL: No fever, chills, weight loss, weakness, or fatigue.

HEENT:

Head: No headache.

Eyes: No visual loss, blurred vision, or double vision.

Ears, Nose, Throat: Reddened throat, sore throat reported.

SKIN:

Clear skin. No rash or itching.

CARDIOVASCULAR:  No chest discomfort. No edema or palpitations.

RESPIRATORY: No cough or sputum.

GASTROINTESTINAL: No nausea, vomiting, anorexia, or diarrhea. No abdominal pain

NEUROLOGICAL: No dizziness, headache, paralysis, numbness, or tingling in the extremities. CN II-12 grossly intact.

MUSCULOSKELETAL: Full range of motion. No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No bruising or bleeding.

LYMPHATICS: Bilateral anterior cervical adenopathy.

PSYCHIATRIC: No reported history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia. Case Study For Patient Complaining Of Bleeding Discussion

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GENITOURINARY/REPRODUCTIVE:

  1. Bleeding after intercourse reported.
  2. Menstrual History: Begun when she was 13. It occurs every 28-32 days and lasts 4-6 days.
  • Breast: Fibrocystic changes bilaterally, no discharge. Bilateral nipple piercings.
  1. VVBSU: Frothy yellow discharge by the cervix, clitoral piercing noted.
  2. Cervix: No cervical motion tenderness.
  3. Uterus: Mid mobile, non-tender.
  • Adnexa: Without masses or tenderness.

ALLERGIES: No reported allergies or history of asthma, hives, eczema, or rhinitis.”

O.

Physical Exam:

General: Susan appears her stated age. No signs of distress. Well-groomed and cooperative.

HEENT:

Head: Normocephalic, atraumatic.

Eyes: Pupils equal, round, reactive to light and accommodation (PERRLA). Bilateral redness noted in the throat.

Ears: Symmetrical, no deformities or discharge.

Nose: No signs of nasal discharge or deformities.

Throat: Reddened throat, anterior cervical adenopathy bilaterally.

Respiratory: Lungs: Clear to auscultation bilaterally.

Cardiovascular: Regular sinus rhythms without murmur or gallop.

Abdominal: Abdomen: Soft, non-tender. Liver palpates normally.

Breasts: Fibrocystic changes bilaterally. No masses, dimpling, redness, or discharge. Bilateral nipple piercings. Case Study For Patient Complaining Of Bleeding Discussion

Genitourinary/Reproductive:

  1. External genitalia (VVBSU): Well-appearing. Slight frothy yellow discharge by the cervix. Clitoral piercing noted.
  2. Cervix: Friable with petechiae. No cervical motion tenderness.
  • Uterus: Mid mobile, non-tender.
  1. Adnexa: Without masses or tenderness.
  2. Perineum: Within normal limits.”

Rectal: Rectum: Within normal limits.

Extremities: Full range of motion in all extremities. Skin clear, no edema.

Neurological: Cranial Nerves (CN) II-12 grossly intact.

Diagnostic results:

Pelvic Examination: Results pending. Expected to provide information on the cervix, uterine position, and adnexal findings.

Pap Smear: Pending results. Aims to identify cervical abnormalities or infections.

STI Testing: Results pending. Includes testing for Chlamydia, Gonorrhea, and other sexually transmitted infections.

Throat Culture: If performed, results pending. Aids to determine the cause of the sore throat, especially if bacterial in origin.

Complete Blood Count (CBC): May be ordered to assess for signs of infection or anemia.

Comprehensive Metabolic Panel (CMP): May be ordered to assess overall health, including liver function.

Imaging (if indicated): Pelvic ultrasound: If abnormalities are suspected based on physical examination. Case Study For Patient Complaining Of Bleeding Discussion

A.

Primary Diagnosis: Cervical Ectropion or Erosion

Cervical ectropion or erosion is the leading consideration for Susan Lang’s symptoms. This diagnosis is supported by the presentation of postcoital bleeding and a friable cervix with petechiae during the physical examination. According to Mishra and Bagade (2023), Cervical ectropion refers to columnar epithelium on the ectocervix, which can be more susceptible to bleeding.

Differential Diagnoses:

  1. Sexually Transmitted Infection (STI):

Given Susan’s sexual history and the concurrent presence of a sore throat, an STI becomes a plausible alternative diagnosis. The symptoms may signal infection with pathogens such as Chlamydia or Gonorrhea. Diagnostic studies, specifically STI testing, will be imperative for confirmation. Reference to CDC guidelines underscores the importance of targeted testing and treatment in suspected STI cases (Lee & Cody, 2020).

  1. Pharyngitis:

The manifestation of a sore throat and systemic symptoms like fever prompts consideration of pharyngitis. Exploring viral and bacterial causes is essential, with a throat culture as a valuable tool to differentiate between them. Reference to principles of appropriate antibiotic use for pharyngitis aids in guiding the diagnostic approach (Sykes et al., 2020)Case Study For Patient Complaining Of Bleeding Discussion.

  1. Pelvic Inflammatory Disease (PID):

PID emerges as another potential consideration due to the pelvic symptoms and relevant risk factors. Nevertheless, definitive verification or ruling out PID requires additional diagnostic research, including imaging and lab tests. A methodical and evidence-based approach is ensured by using medical guidelines about the PID diagnosis criteria (Brun et al., 2020).

  1. Diagnostic Studies:
    1. Pelvic examination, including Pap smear and STI testing.
    2. Throat culture to assess for pharyngitis.
    3. Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) for baseline assessment.
  1. Referrals:
    1. Gynecology specialist for further evaluation of cervical ectropion or erosion.
    2. Infectious disease specialist if STI is confirmed.
  1. Therapeutic Interventions:
    1. Topical treatments for cervical ectropion if confirmed.
    2. Antibiotics if bacterial pharyngitis is diagnosed.
    3. Symptomatic management for viral pharyngitis.
  1. Education:
    1. Patient education on the nature of the conditions diagnosed.
    2. Safe sexual practices and prevention of STIs.
  1. Disposition:
    1. Outpatient follow-up for cervical ectropion management.
    2. Further follow-up as needed based on diagnostic results.

Reflection

Reflecting on this case, I agree with the initial diagnostic approach and outlined plan. Based on the patient’s symptoms and the examination results, the differential diagnoses consider infectious and gynecological etiologies. It is obvious how important it is to educate patients about safe sexual behaviour and the need for routine gynecological exams. I now understand the value of an all-encompassing strategy incorporating general health and gynecological factors. In the future, I would ensure that patients receive comprehensive instruction on preventive measures for gynecological health, particularly regarding quitting smoking. Case Study For Patient Complaining Of Bleeding Discussion

Health Promotion and Disease Prevention

Since smoking hurts gynecological health, health promotion should include smoking cessation counselling, taking into account the patient’s age and risk factors. It is also critical to stress the importance of routine gynecological exams and STI prevention via safe sexual behaviour. Effective disease prevention requires adjusting health promotion tactics to the patient’s socioeconomic status and cultural background.

References

Brun, J. L., Castan, B., de Barbeyrac, B., Cazanave, C., Charvériat, A., Faure, K., … & Graesslin, O. (2020). Pelvic inflammatory diseases: Updated French guidelines. Journal of gynecology obstetrics and human reproduction49(5), 101714. https://doi.org/10.1016/j.jogoh.2020.101714

Lee, A. S., & Cody, S. L. (2020). The stigma of sexually transmitted infections. Nursing Clinics55(3), 295-305. https://doi.org/10.1016/j.cnur.2020.05.002

Mishra, M., & Bagade, T. (2023). Review of management of Cervical Ectropion using Traditional Ayurvedic Interventions. Journal of Ayurveda and Integrated Medical Sciences, 8(3), 55-62. https://doi.org/10.21760/jaims.8.3.10

Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T., & Beyea, J. A. (2020). Pharyngitis: approach to diagnosis and treatment. Canadian Family Physician, 66(4), 251-257. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc7145142/

For this week’s discussion assignment, please post your FOCUSED SOAP NOTE and post your primary diagnosis. Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)

Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations. Your primary diagnosis, additional questions, and types of symptoms are what this assignment and grading are focused on. Your critical thinking for this assignment. NEED 3 Scholarly Resources. APA format Case Study For Patient Complaining Of Bleeding Discussion

 Case Study 2 (Students with last names I-Q will participate in the discussion on this patient)

Susan Lang is a 24-year-old Caucasian female presenting to the clinic complaining of bleeding after intercourse. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / ETOH only on weekends, 6-8 hard liquor/ daily marijuana smoking. Gyn history is the onset of menses at age 13, menses every 28-32 days, lasting 4-6 days, and using 3 tampons daily. She has some cramping during her menses for which she takes Midol. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for the past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies.

Susan’s vital signs were taken and were temperature 97.8, pulse 68, BP 112/64, height 5’6”, and weight 118 lbs. (which was the same as last year). BMI 19.04 Case Study For Patient Complaining Of Bleeding Discussion

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  • HEENT: WNL except for some anterior cervical adenopathy bilaterally, and throat appears reddened.
  • Lung: clear to auscultation
  • CV: regular sinus rhythms without murmur or gallop
  • Abd: soft, non-tender, liver normal,
  • Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.
  • VVBSU: WNL, slight frothy yellow discharge by the cervix, clitoral piercing noted
  • Cervix: friable, some petechia no cervical motion tenderness.
  • Uterus: mid mobile, non-tender
  • Adnexa: without masses or tenderness
  • Perineum: wnl
  • Rectum: wnl
  • Extremities: full ROM, skin clear, no edema, reflexes 1+.
  • Neurological: CN II-12 grossly intact. Case Study For Patient Complaining Of Bleeding Discussion

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