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Case Study Of A Patient Complaining Of Brown Discharge Discussion

Case Study Of A Patient Complaining Of Brown Discharge Discussion

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Case Study Scenario

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 had a colonoscopy 1 year ago, all normal. Her pap history is normal with her last pap 2 years ago reporting 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: Case Study Of A Patient Complaining Of Brown Discharge Discussion

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  • 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

QUESTIONS:

  1. What other information do you want?
  2. What is your differential diagnosis?
  3. What testing would you order? Case Study Of A Patient Complaining Of Brown Discharge Discussion

Update:

CBC comes back within normal limits; pelvic ultrasound reveals the uterus 10 x 5 x 4 cm with a 2 cm endometrial stripe. Ovaries are not visualized. Endometrial biopsy demonstrated copious amounts of white and red tissue. Subsequently, pathology confirms endometrial cancer, and she is referred to GYN oncology.

Discuss testing to see if she has Lynch Syndrome based on her diagnosis of endometrial cancer, a sister with premenopausal breast cancer, and a brother who passed from colon cancer.

Classroom Resources

  • Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.
    • Chapter 17, “Breast Conditions” (pp. 337-349)
    • Chapter 32, “Anatomy and Physiologic Adaptations of Normal Pregnancy” (pp. 677–673)
    • Chapter 19, “Pregnancy Diagnosis, Decision-Making support, and Resolution” (pp. 367-379

GENERAL GUIDELINES FOR HEALTH SCREENINGS

  • American Academy of Family Practice (AAFP). (2020). Browse AAFP clinical recommendationsLinks to an external site.. https://www.aafp.org/home.html
  • American Cancer Society, Inc. (ACS). (2020). Cancer A-ZLinks to an external site.. https://www.cancer.org/
    Note:As you review this resource, select the “Cancer A-Z” topic in the navigation to review information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin.
  • American College of Obstetricians and Gynecologists (ACOG). (2020). Clinical topicsLinks to an external site.. https://www.acog.org/
    Note: As you review this source, make sure to navigate to the “Topics” section in the navigation to review the clinical topics.
  • HealthyPeople 2030. (2020). Healthy People 2030 FrameworkLinks to an external site..  https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework
  • S. Preventive Services Task Force (USPTFS). (2017, September). Search and Filter All Recommendation TopicsLinks to an external site.. https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P&searchterm=

FNP RESOURCES

  • Centers for Disease Control and Prevention. (CDC). (n.d.). Disease & conditionsLinks to an external site.. https://www.cdc.gov/DiseasesConditions/
  • The American Association of Nurse Practitioners (AANP). (2020). AANP practice: Clinical Resources, Business, acumen and opportunities for professional recognitionLinks to an external site.. https://www.aanp.org/practice

GERIATRIC RESOURCES

  • Nicholas, J. A., & Hall, W. J. (2011). Screening and preventive services for older adultsLinks to an external site.. The Mount Sinai Journal of Medicine, New York, 78(4), 498–508. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1002/msj.20275 Case Study Of A Patient Complaining Of Brown Discharge Discussion

Episodic/Focused SOAP Note

Patient Information:

TS, 56, Female, African American

S.

CC (chief complaint): Brown discharge for several days last week.

HPI: Ms. Thelma Smith is a 58-year-old African American female presenting with a chief complaint of brown discharge that occurred for several days last week. She describes the location as the vaginal area. The onset of the brown discharge began last week, and she characterizes it as brown blood. She denies associated signs and symptoms such as pain or tenderness in the cervical area. The timing of the discharge is not specified. There are no exacerbating or relieving factors mentioned. She rates the severity of the discharge as bothersome.

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Current Medications: Metformin and Glipizide

Allergies: No known allergies to medications, food, or environmental factors.

PMHx:

  1. Type 2 diabetes, controlled with glipizide and metformin (last A1C 7.5)
  2. Normal mammograms and colonoscopy 1 year ago
  • Last Pap smear 2 years ago, normal with NILM, HPV negative, atrophic changes, no endocervical cells noted.

Soc & Substance Hx: No information provided about Soc & Substance Hx.

Fam Hx:

  1. Sister with premenopausal breast cancer
  2. Brother who passed from colon cancer
  • No further information provided about other first-degree relatives

Surgical Hx: No information provided.

Mental Hx: No information provided.

Violence Hx: No information provided.

Reproductive Hx:

Menstrual history: Last menstrual period (LMP) not provided

Gravida and Parity: G0 (never pregnant)

Contraceptive use: Information not provided

Sexual activity: Information not provided

Additional Information Needed:

  1. Menstrual History: It would be valuable to obtain a detailed menstrual history. This would entail any irregularities, changes in menstrual flow, and the occurrence of postmenopausal bleeding.
  2. Pregnancy History: It would be imperative to ask about any history of miscarriages, ectopic pregnancies, or any issues related to fertility although the patient is G0 (nulligravida)Case Study Of A Patient Complaining Of Brown Discharge Discussion.
  • Gynecological and Obstetric History: It would be vital to explore any previous gynecological procedures, surgeries, or complications related to the reproductive system. Details about her prenatal care could be relevant.
  1. Sexual History: It would b essential to inquire about sexual activity, contraception methods, and any recent changes in sexual practices. This might uncover factors that contribute to the present complaint.
  2. Recent Medication Changes: It is important to know if there have been any recent changes in her medications, dosage adjustments, or new prescriptions that could be associated with the reported symptoms.
  3. Systemic Symptoms: It would be imperative to ask about the presence of any systemic symptoms such as weight loss, fatigue, or changes in appetite. This could provide clues to the overall health status.
  • Family History: While the case mentions a brother who passed from colon cancer, additional information about other family members’ health history, especially regarding gynecological and reproductive cancers, may be crucial. Case Study Of A Patient Complaining Of Brown Discharge Discussion

ROS:

GENERAL: No weight loss, fatigue, or malaise.

SKIN: No rashes, lesions, or changes in moles.

HEAD: No headaches, dizziness, or head injuries.

EYES: No vision changes, eye pain, or redness.

EARS, NOSE, THROAT: No hearing loss, ear pain, or sinus congestion.

RESPIRATORY: No shortness of breath, cough, or wheezing.

CARDIOVASCULAR: No chest pain, palpitations, or swelling.

GASTROINTESTINAL: Brown discharge reported, no abdominal pain, nausea, or vomiting.

GENITOURINARY: No dysuria, hematuria, or changes in urinary habits.

MUSCULOSKELETAL: No joint pain, stiffness, or swelling.

NEUROLOGICAL: No numbness, tingling, or weakness.

PSYCHIATRIC: No mood changes, anxiety, or depression.

ENDOCRINE: No excessive thirst, hunger, or changes in weight.

HEMATOLOGIC/LYMPHATIC: No easy bruising or bleeding.

ALLERGIC/IMMUNOLOGIC: No allergies or immunodeficiency reported. Case Study Of A Patient Complaining Of Brown Discharge Discussion

O.

Physical exam:

General: Obese appearance, BMI 43.90, no signs of distress.

Head: Normocephalic, atraumatic.

Eyes: No conjunctival pallor, pupils equal and reactive to light.

Ears, Nose, Throat: No abnormalities noted in the external ears, nasal passages, or throat.

Respiratory: Respirations at 12 breaths per minute, no respiratory distress.

Cardiovascular: Blood pressure 140/88, pulse 82, regular rhythm, no murmurs or gallops.

Abdomen: Soft, obese, bowel sounds present, no tenderness or palpable masses.

VVBSU (Vulva, Vagina, Bilateral adnexa, Cervix, Uterus): Brown discharge noted, cervix shows brown blood from os, no cervical motion tenderness, unable to assess uterus and adnexa due to body habitus.

Neurological: Oriented to person, place, and time, no focal deficits.

Musculoskeletal: No joint deformities or limitations in range of motion.

Skin: No rashes, lesions, or abnormalities.

Pelvic Ultrasound: Uterus measures 10 x 5 x 4 cm with a 2 cm endometrial stripe, ovaries not visualized.

Diagnostic results:

  1. CBC: Within normal limits.
  2. Pelvic Ultrasound: Uterus size and endometrial stripe noted; ovaries not visualized.
  3. Endometrial Biopsy: Demonstrated copious amounts of white and red tissue, confirming endometrial cancer.
  4. Pathology: Confirmed the diagnosis of endometrial cancer.

A.

Primary and Differential Diagnoses

  1. Primary Diagnosis:

Endometrial Cancer: The primary diagnosis of endometrial cancer is supported by the findings of the pelvic ultrasound. These findings revealed a 2 cm endometrial stripe and subsequent endometrial biopsy which demonstrated copious amounts of white and red tissue. The pathology results confirmed the presence of endometrial cancer. According to the American Cancer Society, abnormal vaginal bleeding, including brown discharge, can be an early sign of endometrial cancer (Crosbie et al., 2022). Additionally, the patient’s age, obesity, and history of atrophic changes in the cervix further contribute to the likelihood of endometrial cancer.

  1. Differential Diagnosis:
  2. Atrophic Vaginitis: Atrophic vaginitis could be considered as a differential diagnosis due to the patient’s age, postmenopausal status, and the presence of atrophic changes noted in her last pap smear. According to the North American Menopause Society, postmenopausal women may experience vaginal atrophy (Poordast et al., 2021). This would lead to symptoms like dryness, irritation, and occasional spotting or brown discharge.
  3. Uterine Fibroids: Uterine fibroids are a consideration due to the patient’s obesity, which is a risk factor for their development. This diagnosis is less likely, however, given the lack of palpable masses on abdominal examination and the ultrasound results that do not specify the presence of fibroid. Uterine fibroids can cause irregular uterine bleeding, according to the American College of Obstetricians and Gynecologists (Giuliani et al., 2020), although imaging tests like ultrasounds and MRIs are typically required for the diagnosis of uterine fibroids.
  4. Cervical Dysplasia: Cervical dysplasia could be considered given the patient’s history of atrophic changes in the cervix. However, the brown discharge and the presence of blood noted in the cervix make endometrial cancer a more likely diagnosis. The American Cancer Society emphasizes that cervical dysplasia may present with abnormal pap smear results, which is not the case in the recent history provided (Frick et al., 2022)Case Study Of A Patient Complaining Of Brown Discharge Discussion.
  1. Endometrial Cancer:
    1. Referral to GYN oncology for further evaluation, staging, and treatment planning.
    2. Consideration of additional imaging studies (CT scan, MRI) to assess the extent of disease.
    3. Genetic counseling and testing for Lynch Syndrome based on family history.
    4. Initiation of education on the diagnosis, treatment options, and potential side effects.
  1. Atrophic Vaginitis:
    1. Symptomatic management with vaginal moisturizers or lubricants.
    2. Education on the use of hormone therapy for atrophic vaginitis if appropriate after consultation with a gynecologist.
  1. Uterine Fibroids:
    1. Consideration of a pelvic MRI to further evaluate the presence of uterine fibroids.
    2. Referral to a gynecologist for discussion of treatment options if fibroids are confirmed.
  1. Cervical Dysplasia:
  1. Colposcopy and cervical biopsy to assess the severity of cervical dysplasia.
  2. Referral to a gynecologist for further management and potential treatment.

Education:

  1. Provide thorough education to the patient on the diagnosis of endometrial cancer, treatment options, and potential outcomes.
  2. Discuss the importance of genetic testing and counseling for Lynch Syndrome.
  • Educate on symptomatic management and treatment options for atrophic vaginitis.

Disposition:

  1. Referral to GYN oncology for ongoing management of endometrial cancer.
  2. Follow-up appointments with appropriate specialists based on diagnostic results.

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Reflection

In reflecting on this case, I agree with the plan to refer the patient to GYN oncology for further evaluation and staging of endometrial cancer. The prompt genetic testing for Lynch Syndrome aligns with evidence-based guidelines for individuals with a personal and family history of related cancers. The consideration of other potential diagnoses like atrophic vaginitis and uterine fibroids is reasonable. This would ensure a comprehensive approach to the patient’s health.

I am now cognizant of the value of approaching diagnosis meticulously and the necessity to work with specialists on complex cases. In the future, I would emphasize more detailed health promotion discussions. I would consider factors like age, ethnicity, and socioeconomic background. It is essential to tailor cancer risk and prevention strategies to each patient’s specific situation. This would help foster better understanding and adherence to preventive measures. Additionally, it would be vital to explore cultural factors that affect healthcare decision-making as this would enhance patient-centered care. Case Study Of A Patient Complaining Of Brown Discharge Discussion

References

Crosbie, E. J., Kitson, S. J., McAlpine, J. N., Mukhopadhyay, A., Powell, M. E., & Singh, N. (2022). Endometrial cancer. The Lancet, 399(10333), 1412-1428. https://doi.org/10.1016/s0140-6736(22)00323-3

Giuliani, E., As‐Sanie, S., & Marsh, E. E. (2020). Epidemiology and management of uterine fibroids. International Journal of Gynecology & Obstetrics149(1), 3-9. https://doi.org/10.1002/ijgo.13102

Frick, A., Azuaga, A., & Abdulcadir, J. (2022). Cervical dysplasia among migrant women with female genital mutilation/cutting type III: A cross‐sectional study. International Journal of Gynecology & Obstetrics157(3), 557-563. https://doi.org/10.1002/ijgo.13921

Poordast, T., Ghaedian, L., Ghaedian, L., Najib, F. S., Alipour, S., Hosseinzadeh, M., … & Hosseinimehr, S. J. (2021). Aloe Vera; A new treatment for atrophic vaginitis, A randomized double-blinded controlled trial. Journal of Ethnopharmacology270, 113760. https://doi.org/10.1016/j.jep.2020.113760 Case Study Of A Patient Complaining Of Brown Discharge Discussion

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