Assignment :
Respond to your colleague’s post and explain how you might think differently about the types of tests or treatment options that your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position
Colleague post: Patient Information:
T.C., 56, Female, Hispanic
S.
CC: This patient was asymptomatic with no chief complaint
HPI: T.C. presented to the office for a transvaginal ultrasound per her request. She reports being asymptomatic but was told by her gynecologist in North Carolina one year ago (10/20/20) that she needed to schedule an appointment for an ultrasound as a diagnostic measure for what they believed to be an ovarian cyst with the possibility of low malignancy.
Current Medications:
Levothyroxine 112 mcg po q daily
Spironolactone 25mg q daily for acne
Escitalopram 10mg 1 x daily for depression
Ibuprofen PRN for pain
Allergies: Neomycin
PMHx: Hypothyroidism; Shingles (7/2018); Depression; childhood immunizations up to date; Flu vaccine 9/2021; Shingrix vaccine (2/2019); Pfizer Covid-19 vaccine x 3; Last tetanus shot 8/2013.
Soc and Substance: Patient is a bank teller at Bank of America, a position she has held for 15 years. She is a member of the LGBTQ community and identifies as a lesbian. She currently lives in a condo with her partner and their 2 dogs. She endorses drinking alcohol socially but denies tobacco and alcohol use.
Family Hx: non-contributory
Surgical Hx: Laparoscopic removal of ovarian cyst – 9/2001; Wisdom teeth removed – 1999
Mental Health: Patient reports a history of depression but is currently taking Escitalopram with positive effect.
Reproductive Hx: Patient has no children. She does not use a method of contraception. Natural menopause occurred at age 51 with the patient’s LMP being in 2016.
ROS:
GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: Denies vision loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, tinnitus, sneezing, congestion, runny nose, or sore throat.
SKIN: Denies rash, itching, or bruising.
CARDIOVASCULAR: Denies chest pain, chest pressure, and chest discomfort. Denies palpitations; Denies edema
RESPIRATORY: Denies SOB, cough, wheezing, or sputum.
GASTROINTESTINAL: Endorses lower abdominal pain “every once in a while” that is not consistent. Denies anorexia, nausea, vomiting, or diarrhea. Denies changes in bowel habits, stool color/consistency, or blood.
GENITOURINARY: Denies dysuria, polyuria, and burning on urination.
NEUROLOGICAL: Denies headache, dizziness, syncope, numbness, or tingling in the extremities. Denies changes in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle pain, back/neck pain, joint pain, or stiffness.
HEMATOLOGIC: Denies anemia, bleeding, or bruising.
LYMPHATICS: Denies enlarged nodes; denies organomegaly
PSYCHIATRIC: Endorses a history of depression; Symptoms are well-controlled with the once daily use of Escitalopram 10mg; Denies self-harm, suicidal, or homicidal ideations.
ENDOCRINOLOGIC: Endorses having hypothyroidism that is well-controlled with daily use of Levothyroxine 112 mcg.
REPRODUCTIVE: Patient is nulliparous; Endorses natural menopause that occurred at age 51. Last menstrual period was documented in 2016. Denies abnormal or malodorous vaginal discharge. Denies being sexually active.
ALLERGIES: Endorses having an allergy to Neomycin which causes a rash and skin inflammation. Denies history of asthma, hives, or eczema.
O.
Vital Signs: B/P 138/84 (left arm, sitting), P 78, Ht: 5’3, Wt: 154 (BMI 27.3 – Overweight)
General: A&Ox3, NAD
A physical exam was not performed on this patient at this visit because she presented to the office as a referral for a transvaginal ultrasound to monitor a previously diagnosed ovarian mass.
Diagnostics:
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Transvaginal ultrasound was performed today in the office: Findings- irregular solid mass with multiple papillary projections.
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CA-125 test
Further diagnostic workup will be done by the gynecologic oncologist.
A.
Differential Diagnoses:
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Epithelial Ovarian Tumor (malignant) – According to the American Cancer Society (2021), approximately 85% to 90% of malignant ovarian cancers are epithelial ovarian carcinomas. There are different types of epithelial ovarian cancer, but this type of cancer means that it starts in the surface layer covering the ovary and grows into the supporting tissue of the ovary. Once the type is known, it is important to determine the stage and grade of the tumor which will dictate treatment. The patient in this case is asymptomatic which according to Doubeni, Doubeni, & Myers (2016), is indicative of the insidious nature of early-stage ovarian cancer which has no symptoms. Her transvaginal ultrasound showed multiple papillary projections which according to Jung et al. (2002), are a distinctive feature of invasive carcinomas.
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Borderline Epithelial Ovarian Tumor (low malignant potential) – According to the Minnesota Ovarian Cancer Alliance (2021), these types of tumors are abnormal cells that form in the tissue covering the ovary and although they have the potential to turn into cancer, they usually do not because they don’t grow into the supporting tissue of the ovary. The patient in this case is postmenopausal and these types of tumors tend to occur in younger women.
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Ovarian cyst – According to Garg (2021), ovarian cysts are fluid-filled sacs that form on the ovaries as a normal part of menstruation during childbearing years or after menopause. They are typically harmless but according to Garg (2021), postmenopausal patients who have ovarian cysts may be at a higher risk for ovarian cancer. The patient in this case was told she had a cyst on her ovary over a year ago in 2020 and was encouraged by her previous provider to follow up with imaging studies but she failed to do so. The image seen today on the transvaginal ultrasound is not a benign ovarian cyst.
P.
This patient’s case was bothersome to me in that she was told one year ago she needed to follow-up on what her doctor in North Carolina considered to be a possible malignancy, and she failed to do so because she was asymptomatic. She presents to our office over a year later requesting an ultrasound and ends up with an immediate referral to a gynecologic oncologist for a tumor that is most likely ovarian cancer. As the patient’s Nurse Practitioner, it is extremely frustrating because our role doesn’t just include diagnosing and managing acute and chronic illnesses. We also play an important role in our patient’s lives as the individual who educates them on the importance of health promotion and prevention, and early screenings to avoid a poor prognosis. Had this patient simply heeded the advice of the doctor in North Carolina, it may have resulted in a different outcome.
I accompanied the patient into the Gynecologists office where she was informed that the images seen today combined with her elevated CA-125 levels, seem to indicate a high suspicion of Epithelial Ovarian Cancer (EOC). She was referred immediately to the gynecologic oncologist for further testing and treatment. According to Chen & Berek (2021), there is evidence that prognosis is improved when EOC staging and cytoreduction is performed by a gynecologic oncologist.
The Gynecologist explained to her that surgery to remove the cancer is usually the first part of treatment, but she may need further treatment like chemotherapy. The specialist will make the final decision on treatment once the cancer is staged and graded. The patient was encouraged to bring her partner with her to see the specialist, as there will be choices she needs to make about her treatment and a good support system will be crucial.
It has been 3 weeks and our office has not yet heard back from this patient after multiple attempts to try and reach her. I pray for her sake she doesn’t wait another year before following up with the specialist.
References
American Cancer Society (2021). About Ovarian Cancer. https://www.cancer.org/cancer/ovarian-cancer/about/what-is-ovarian-cancer.html.
Chen, L., MD, Berek, J.S., MD (2021). Overview of Epithelial Carcinoma of the Ovary, Fallopian Tube, and Peritoneum. https://www.uptodate.com/contents/overview-of-epithelial-carcinoma-of-the-ovary-fallopian-tube-and-peritoneum.
Doubeni, C.A., MD, MPH, Doubeni, A.R.B., MD, MPH, Myers, A.E., MD, MPH (2016). Diagnosis and Management of Ovarian Cancer. American Family Physician, 93(11):937-944. https://www.aafp.org/afp/2016/0601/p937.html.
Garg, R., MD (2021). Ovarian Cysts. Cancer Treatment Centers of America. https://www.cancercenter.com/cancer-types/ovarian-cancer/symptoms/ovarian-cysts.
Jung, S.E., Lee, M.L., Rha, S.E., Byun, J.Y., Jung, J.I., Hahn, S.T. (2002). CT and MR Imaging of Ovarian Tumors with Emphasis on Differential Diagnosis. Radiological Society of North America, 22(6):1311-1312. https://doi.org/10.1148/rg.226025033.
Minnesota Ovarian Cancer Alliance (2021). Benign Epithelial Ovarian Tumors. https://mnovarian.org/benign-epithelial-ovarian-tumors/.
Topic: Consider a case study related to a patient that demonstrates a gynecological disease process in your practicum experience or professional practice that would be your biggest challenge as a clinician. Note: Possibly use your “FNP or AGPCNP Skills and Procedures Self-Assessment” in your practicum experience to guide your case study selection.
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Review the Learning Resources for this week and specifically review the clinical guideline resources specific to your proposed case study.
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Use the Focused SOAP Note Template found in the Learning Resources to support your discussion. Complete a Focused SOAP note and critically analyze this and focus your attention on the diagnostic tests.
Based on your case study, post the following:
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POST A Focused SOAP NOTE only and describe your case study.
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Provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
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Define what you believe is the most important diagnosis. Be sure to include the priority in conducting your assessment.
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Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.
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Also, share with your colleagues your experiences as well as what you learned from these experiences.
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