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Comprehensive Approach To Patient Care Discussion Paper

Comprehensive Approach To Patient Care Discussion Paper

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Hello, thank you for providing a comprehensive and elaborate SOAP note regarding patient T.S., an African-American woman of 58 years old, who has been experiencing brown discharge for a week. A full picture of the patient’s medical history, family history, and the outcomes of diagnostic testing is provided by your comprehensive examination. I agree with your diagnosis of endometrial cancer (C54.1) based on the positive pelvic exam results, particularly the large amount of red and white tissue seen in the endometrial sample and the brown discharge. The pertinent research you cited regarding the connection between obesity and endometrial cancer as well as the influence of hormone metabolism on tumor development gives your diagnostic reasoning a significant amount of context. Comprehensive Approach To Patient Care Discussion Paper

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Lynch Syndrome (Z15.09) is a legitimate concern, especially given a positive family history of colon and breast cancer. A genetic disorder called Lynch Syndrome has been linked to an increased chance of getting many types of cancer, especially in the reproductive and gastrointestinal systems (Ojha & Laslett, 2023)Comprehensive Approach To Patient Care Discussion Paper. The patient may have inherited genetic alterations that predispose them to various malignancies if there is a family history of a particular malignancy. In light of the possible influence on the patient’s cancer risk, further investigation of this factor via genetic testing makes sense. In addition to confirming the existence of Lynch Syndrome, genetic testing can yield important data for creating a thorough and individualized care plan as discussed by Duraturo et al. (2029). The timely detection of genetic predispositions can provide focused monitoring, risk mitigation strategies, and perhaps more effective interventions, thereby improving the patient’s overall care management.

A thorough awareness of the patient’s overall health is seen in the inclusion of Vaginal Atrophy (N95.2) as a potential diagnosis in addition to Lynch Syndrome (Santoro et al., 2022). The pelvic examination’s good results of atrophic alterations support the theory that menopausal hormone changes may be a factor in vaginal atrophy. Being aware of this is important since fixing hormone imbalances can have a significant impact on alleviating physical symptoms as well as enhancing the patient’s overall quality of life. The identification and treatment of vaginal atrophy might result in focused treatments, such as hormone replacement therapy or other suitable procedures, with the goal of symptom relief and avoidance of problems. The patient-centered viewpoint exhibited by the holistic approach to the patient’s health, which takes into account both hormonal and genetic predispositions, can greatly improve the effectiveness of the overall treatment plan (Ojha & Laslett, 2023).

As for available treatments, your suggestion that surgery be the first course of action is in line with what is considered conventional practice for endometrial cancer. In the event of a high risk of recurrence, your consideration of Paclitaxel and Carboplatin shows a deliberate approach to possible postoperative care. The significance of prompt referrals cannot be overstated, and your recommendation for a Gyn Oncology referral is a good one. Including experts in the care plan will provide a multidisciplinary strategy and all-encompassing patient condition management (Duraturo et al., 2019)Comprehensive Approach To Patient Care Discussion Paper.

In conclusion, the comprehensiveness, reasonable thinking, and evidence-based methodology of your soap note are commendable. A comprehensive approach to patient care is demonstrated by your careful evaluation of alternative diagnoses and available treatments. I appreciate the care you took in handling this difficult issue, and I wholeheartedly support your diagnosis and treatment plan. A testament to your dedication to providing thorough and efficient healthcare is your ability to incorporate clinical information and apply it wisely. In addition to demonstrating your commitment to delivering high-quality, patient-centered medical care, this well-thought-out strategy inspires confidence in the recommended plan of action.

References

Duraturo, F., Liccardo, R., De Rosa, M., & Izzo, P. (2019). Genetics, diagnosis and treatment of Lynch syndrome: Old lessons and current challenges. Oncology letters, 17(3), 3048–3054. https://doi.org/10.3892/ol.2019.9945

Ojha, S.K., & Laslett, N. (2023, July 16). Hereditary Nonpolyposis Colon Cancer. In StatPearls [Internet]. StatPearls Publishing. Retrieved January 17, 2024, from https://www.ncbi.nlm.nih.gov/books/NBK564511/

Santoro, N., Roeca, C., Peters, B. A., & Neal-Perry, G. (2021). The Menopause Transition: Signs, Symptoms, and Management Options. The Journal of clinical endocrinology and metabolism, 106(1), 1–15. https://doi.org/10.1210/clinem/dgaa764

Respond to your colleagues’ posts on and explain how you might think differently about the types of tests or treatment options your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position. Need 2 Scholarly References. APA Format. Colleagues POST and class resources are Below. Comprehensive Approach To Patient Care Discussion Paper

 Episodic/Focused SOAP Note Template

 Patient Information:

Initials, T.S, Age: 58, Sex: Female, Race: African-American

S.

CC (chief complaint): “Brown discharge for a week.”

HPI: The patient is T.S a 58 y/o African American female. She presents to the office today with complaints of brown discharge. The discharge started last week, occurred for several days. Denies itching or foul odor. Denies having problems with night sweats, painful urination, urgency or increased urination.

Current Medications:

  • Metformin 850 mg, daily
  • Glipizide

 

Allergies: NKDA, NKFA

PMHx: The patient has type 2 diabetes well controlled with Glipizide and Metformin. She reports frequent visit to healthcare provider. She is up-to date with immunizations, colonoscopy, and mammograms. Last colonoscopy was one year ago.

Soc & Substance Hx: Negative for marijuana, cocaine, heroine or any illicit drug use. The patient likes fast foods and stays indoors most of the time. She rarely exercises. She denies any secondhand exposure to tobacco smoke. She has smoke detectors in her house, wears safety belt when driving.

Fam Hx:

  • Sister -premenopausal breast cancer
  • Brother-died from colon cancer

Surgical Hx: No history of any surgery or complex procedures.

Mental Hx: No history of depression, mood swings, or any anxiety disorders.

Violence Hx:  No history of verbal abuse, physical harm, insults or hits.

Reproductive Hx: The pt. is G0 P0. She denies any history of pregnancy. She reports noticing brown discharge for several days last week. Her last mammogram was normal, negative pap history. She also reports negative HPV. Her onset of the menarche was 12 y/o. Her periods were regular, moderate bleeding, with cramps. She is currently in her post-menopausal age. Denies history of STIs. Comprehensive Approach To Patient Care Discussion Paper

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ROS:

GENERAL: patient denies any fatigue, fever, chills or any sleeping problems. She also denies any changes to her appetite. No night sweats reported.

HEENT: Denies headaches or any head trauma. No blurry vision, double vision, itchy eyes reported. Pt also denies runny nose, sinus congestion or any pressure behind her eyes. No ear pain, discharge or any hearing problems. No bleeding gums or sore throat reported.

SKIN: Denies dry skin, moles, or rashes.

CARDIOVASCULAR: Denies cold skin, blue skin, irregular heartbeats or swelling in her lower extremities.

RESPIRATORY: No chest pain, tightness, sneezing, cough, sputum or shortness of breath reported

GASTROINTESTINAL: Denies abdominal pain or cramps, nausea and vomiting.

NEUROLOGICAL: No syncope, dizziness, lightheadedness or any history of seizures.

MUSCULOSKELETAL: No muscle pain, stiff joints, muscle weakness, or any mobility issues reported.

HEMATOLOGIC: Patient reports abnormal bleeding. However, she denies any history of anemia.

LYMPHATICS: No swollen lymph nodes reported

PSYCHIATRIC: Denies mood swings or any anxiety problems related.

ENDOCRINOLOGIC: No increased urination, sweating, thirst or polyphagia.

GENITOURINARY/REPRODUCTIVE: pt is G0P0. She has never been able to get pregnant. She is currently in menopausal status. Reports brown vaginal discharge but pelvic pain, burning sensation, painful urination or any itchiness. Comprehensive Approach To Patient Care Discussion Paper

ALLERGIES: none

O.

Physical exam:

Vital signs: Blood pressure 140/88, Pulse 82, temperature 98.1, respiration 12, height 5’6”, weight 272 lbs making a BMI of 43.90.

General: Patient is alert and oriented. She is cooperative, no signs of acute distress noted. She is obese, neatly dressed, and answers questions asked.

HEENT: No visible abnormal signs, PERRL, no sclera icterus noted. Intact TM, non-tender sinuses. No erythema or adenopathy noted.

Neck: supple, smooth with no goiter

Cardiovascular: S1 and S2 heart sounds, no bruits noted, regular sinus rhythm.

Respiratory: Lungs clear to auscultation. Unlabored respiration noted.

Abdomen: soft and obese.

Diagnostic results:

Pelvic exam:

VVBSU-positive for brown discharge.

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.

CBC- within normal limits.

Pelvic ultrasound: It is an essential test widely used in the evaluation of women with PMB. It helps in measuring the endometrial thickness The endometrial pathology is strongly reduced in the presence of an endometrial ultrasound with an endometrial thickness < 4 mm (Briejer, et al, 2018). T.S ultrasound reveals that her uterus 10 x5x4 cm with a cm endometrial stripe.

Endometrial Biopsy: This is a simple and effective office-based procedure that samples the endometrium. Will & Sanchack, (2023) states that a postmenopausal bleeding must be investigated to investigate the underlying cause.  The results : copious amount of white and red tissue. Comprehensive Approach To Patient Care Discussion Paper

A.

Diagnosis

  • Endometrial cancer (C54.1): It is a major health concern especially in postmenopausal women. its commonest presenting complaint is postmenopausal bleeding. It is cancer of the uterine corpus, fourth most common malignancy. There is a close relationship between obesity and EC cases. According to Orekoya, et al, (2016), endometrial cancer is a hormone dependent disease. Obesity affects hormone metabolism thereby increasing the aromatization of androstenedione to estrone in adipose tissues. In addition, it enhances the levels of estrogen thereby creating good environment for tumor formation. The key risk factors associated with this disease include physical inactivity, early menarche, and diabetes. The diagnosis of this condition is more common in patients with abdominal thickness of more than 4 mm (Sebastian, et al, 2021). This is the primary diagnosis for this patient. It was confirmed through the pelvic ultrasound and the endometrial biopsy.
  • Lynch Syndrome (Z15.09): This is a genetic disorder that is associated with increased mutations in the germline especially the MMR genes. Mutations in these genes increases the patients in risks of developing colorectal cancer, and carcinomas of endometrium, small intestine, ovary, upper urinary tract and skin (Daraturo, et al, 2019). This diagnosis should be considered since the patient has a positive family history of breast cancer and colon cancer.
  • Vaginal Atrophy (N95.2): This is the thinning of the vaginal epithelium and decreased cervical secretions. It typically develops due to lack of estrogen due to menopause. According to Goodman, (2020), the hypoestrogenic changes causes the endometrial surfaces to contain little or no fluid to prevent intracavitary friction which in-turn may result in microerosions of the surface which are prone to light bleeding. This diagnosis should be considered since the pelvic examination is positive atrophic changes.

 

Treatment Options:

  • Surgery is the primary treatment. Considering that she is in the early stage, she may require no additional treatment (Vistard & Bjorge, 2023). However, if the patient is in high risk of recurrence, Carboplatin and Paclitaxel medications should be considered. Comprehensive Approach To Patient Care Discussion Paper

Referrals: Gyn Oncology.

 

References

Breijer, M. C., Timmermans, A., Van Doorn, H. C., Mol, B. W., & Opmeer, B. C. (2018). Diagnostic strategies for postmenopausal bleeding. Obstetrics and Gynecology International2010, 1-5. https://doi.org/10.1155/2010/850812Links to an external site.

Duraturo, F., Liccardo, R., De Rosa, M., & Izzo, P. (2019). Genetics, diagnosis and treatment of lynch syndrome: Old lessons and current challenges (Review). Oncology Letters. https://doi.org/10.3892/ol.2019.9945Links to an external site.

Goodman, A. (2020). Approach to the patient with postmenopausal uterine bleeding. Evidence-Based Clinical Decision Support System| UpToDate | Wolters Kluwer. https://www.uptodate.com/contents/approach-to-the-patient-with-postmenopausal-uterine-bleeding#H542181424Links to an external site.

Orekoya, O., Samson, M. E., Trivedi, T., Vyas, S., & Steck, S. E. (2016). The impact of obesity on surgical outcome in endometrial cancer patients: A systematic review. Journal of Gynecologic Surgery32(3), 149-157. https://doi.org/10.1089/gyn.2015.0114Links to an external site.

Sebastian, A., Neerudu, S. R., Rebekah, G., Varghese, L., Regi, A., Thomas, A., Chandy, R. G., & Peedicayil, A. (2021). Risk factors for endometrial carcinoma in women with postmenopausal bleeding. The Journal of Obstetrics and Gynecology of India71(4), 417-423. https://doi.org/10.1007/s13224-021-01464-3Links to an external site.

Vistad, I., & Bjørge, L. (2023). Advanced endometrial cancer: New medical treatment options on the horizon. Acta Obstetricia et Gynecologica Scandinavica102(2), 128-129. https://doi.org/10.1111/aogs.14499Links to an external site. Comprehensive Approach To Patient Care Discussion Paper

Class 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=

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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 Comprehensive Approach To Patient Care Discussion Paper

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