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:
- 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:
- What other information do you want?
- What is your differential diagnosis?
- What testing would you order?
Update:
CBC comes back within normal limits; pelvic ultrasound reveals uterus 10x5x4 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.
Also, consider testing to see if she has Lynch Syndrome based on her endometrial cancer, a sister with premenopausal breast cancer, and a brother who passed from colon cancer.
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.
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:
- 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:
- What other information do you want?
- What is your differential diagnosis?
- What testing would you order?
Update:
CBC comes back within normal limits; pelvic ultrasound reveals uterus 10x5x4 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.
Also, consider testing to see if she has Lynch Syndrome based on her endometrial cancer, a sister with premenopausal breast cancer, and a brother who passed from colon cancer.
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.