Endometrial Cancer Diagnosis

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:

1. What other information do you want?
2. What is your differential diagnosis?
3. 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.

SOAP Note:

Subjective: Thelma Smith, a 58-year-old African American female, presents with a complaint of brown discharge for several days last week. Her medical history includes type 2 diabetes controlled with glipizide and metformin (A1C 7.5), nulligravida, and normal recent mammograms and colonoscopy. Her last pap 2 years ago was normal, showing NILM, HPV negative, atrophic changes, and no endocervical cells noted.

Objective:

• Vital signs: Temperature 98.1°F, BP 140/88 mm Hg, pulse 82 bpm, respirations 12/min. Height: 5’6”, weight: 272 lbs (BMI 43.90).
• Abdomen: Soft, obese, normal bowel sounds.
• Vaginal examination: Brown discharge observed.
• 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.

Assessment:

Differential Diagnosis:

1. Endometrial Cancer: Given the clinical presentation of brown discharge, obesity, and the findings of a thickened endometrial stripe on ultrasound, endometrial cancer is a significant concern.
2. Endometrial Hyperplasia: Hyperplasia can also present with abnormal uterine bleeding, especially in overweight or obese individuals with diabetes.
3. Uterine Fibroids: While less likely, uterine fibroids could contribute to abnormal bleeding.

Priority Diagnosis: The most important diagnosis to consider in this case is endometrial cancer. This is the primary concern due to Thelma’s age, the presence of abnormal uterine bleeding, and the ultrasound findings of a thickened endometrial stripe. Early detection and treatment are crucial for better outcomes.

Diagnostic Tests and Treatment Recommendations:

1. Endometrial Biopsy: Given the suspicion of endometrial cancer, an endometrial biopsy should be performed to confirm the diagnosis definitively. This has already been performed and confirmed endometrial cancer.
2. CT or MRI Pelvis: To assess the extent of disease and identify any possible metastasis.
3. Referral to Gynecologic Oncology: As the patient has been confirmed with endometrial cancer, she should be referred to a gynecologic oncologist for further evaluation and treatment planning. Surgical staging, such as a total hysterectomy with bilateral salpingo-oophorectomy, may be indicated. Depending on the stage and grade of the cancer, radiation therapy and chemotherapy may also be recommended.

Regarding Lynch Syndrome Evaluation: Given Thelma’s history of endometrial cancer, a family history of premenopausal breast cancer in her sister, and her brother’s history of colon cancer, it would be advisable to consider Lynch Syndrome testing for her. This should be discussed with a genetic counselor to assess her risk and the need for genetic testing.

In summary, Thelma Smith presents with concerning symptoms of brown discharge, and the diagnosis of endometrial cancer has been confirmed. The priority is to manage her endometrial cancer promptly with the involvement of a gynecologic oncologist, and consideration for Lynch Syndrome testing should be discussed with a genetic counselor.