Reply to discussion post

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.A is a 39 y/o Caucasian patient

CC– of heaviness in the abdomen and lower back, irregular, heavy and painful menstruation, 1-2 prior to menstrual flow might have vaginal blood spot, painful intercourse.

HPI- T.A is a 39 y/o Caucasian patient, presented to the clinic with complaints of pain and heaviness in her back and abdomen for the last 8 months

Location- lower abdominal pain

Onset- 11 months ago

Character- vague discomfort and heavy and prolonged menstrual flow, mild dull and crampy abdominal pain, heaviness feeling in the lower back

Associated symptoms – discomfort intercourse, fatigue.

Timing- during menses – heavy bleeding, discomfort during sexual intercourse.

Exacerbating/ relieving factors- ibuprofen help to decrease the painful menses.

Current medications- ibuprofen 400mg q 8 hours the first 2 days of the menses, iron 65 mg twice a day for 3 months.

Allergies– none

PMHx–

• Appendectomy in her childhood

• Cholecystectomy 10 years ago.

• Dysmenorrhea for the last 11 months.

• 2 D & C after 2 miscarriages

• Menorrhagia in the last 11 months

• Anemia – iron deficiency anemia- 2weeks ago

• Urine incontinence  in the last 3 months.

Soc & Substance Hx- she is a teacher for 5th grade at a local school, lives with her mother in an apartment that has good conditions. She does not smoke. She drinks one cup of wine occasionally, does not use recreation drugs.

 

Fam Hx-

Mother alive- she is 59 y/o – had hysterectomy at age 51- reason is fibroma that caused to her severe anemia and pain in her lower back.

Father- is alive 58 y/o- a heavy smoker, has hypercholesterolemia

Sister- is 29 y/o has history of dysmenorrhea, has one son, he is 8 y/o

Maternal and paternal grand father and mother- unknown histories.

Mental health- feels anxious in the last few months because of the dysmenorrhea

Reproductive History-

Menstrual History- menarche at age 11 y/o irregular for the first 2 years. Her menses used to occur every 27 days and lasts 4 days, heavy the first and second day without clots.  In the last 8-10 months her menses occur every 20- 23 day, last longer- 6-8 days, heavy for the first 4 days with some clots. She complaints of mild dark red vaginal secretion 1 to 2 days prior to her menses, and painful intercourse.

LMP- started 7 days ago and still is running

Miscarriages- gestational age was 8 weeks when she was 21 y/o

                     Gestational age was 10 weeks old when she was 27 y/o

Contraceptive- oral contraceptive- never she used, she is using condoms; type of intercourse- vaginal and oral.

 

ROS-

• General- negative for weight loss or gain, denies fever, feels fatigue all the time and weak. The patient feels fatigue and anxious for no reason as she says.

• Vitals- T 98.7F, BP 119/68,  HH70,   RR22,   Height 5’7’’,   W187lbs

• HEENT- Eyes- negative for vision loss or blurred or doubled vision. Ears, Nose, Throat- negative for hearing loss, sneezing, congested nose or sore throat.

• SKIN- denies rash or itching

• CARDIOVASCULSR- no chest pressure or pain, denies palpitations.

• RESPIRATROY- denies cough, wheezing or shortness of breath.

• GASTROINTESTINAL-denies anorexia, vomiting. There is no nausea or vomiting. Has heaviness feeling in the lower part of her abdomen and cramps during her menses period. positive for some urine intolerance

• GENITOURINARY- feels some pressure on her bladder. Positive for urinary frequency and urgency.  

• NEUROLOGICAL- denies headache, dizziness or changes in bladder or bowel movement.

• MUSCULOSKELETAL- positive for feeling of some heaviness in the lower back.

• HEMATOLOGIC- positive for iron deficiency anemia.

• LYMPHATICS- denies history of splenectomy.

• PSYCHIATRIC- no history of depression, feels anxious in the last few months because of her prolonged menses.

• ENDOCRINOLOGIC- denies cold or heat intolerance.

• REPRODUCTIVE- denies pregnancy, positive for heavy bleeding that started 7 days ago, positive for some clots-about 1 inch in size.  Pregnancy- 2, miscarriage 2. LMP 7 days ago and still running

• ALLERGIES- denies history of asthma or eczema.

 

O.

Physical exam– patient looks pale and exhausted.

Skin- is dry and pale.

Abdominal Exam- the abdomen looks rounded, the uterus is hard on palpation, due to the heavy bleeding there was no vaginal exam.

Diagnostic results-

• Pregnancy test- negative

• CBC- anemia- iron deficiency anemia -ferritin- 11ng/ml

• Platelets counts- 142,000

• Endometrial biopsy -2 weeks ago- negative for malignancy

• Transabdominal and transvaginal ultrasound results- 9.5 cm submucosal fibroid, and 2.3 cm cervical fibroid.

• MRI- is the preferred method for accurately characterizing pelvic masses (Wilde & Scott-Barrett 2009). Her MRI image showed multiple intramural fibroids, the largest measures 9.2 cm.

 

 

Primary diagnosis– uterine fibroids- uterine fibroids are the most common benign tumors in women of the reproductive age. Heavy menstrual bleeding, dysmenorrhea, dyspareunia, and pressure complaints may prevent women from participating in normal daily activities and significant decrease their quality of life (Middelkoop et al., 2021).

Uterine fibroids are common cause of heavy menstrual bleeding and pain, and are treated with combination of oral gonadotropin-releasing hormone-receptor antagonist, estradiol, and norethindrone acetate, once daily (Al-Hendy et al., 2021).

Treatment options range for medicinal treatment, to minimally invasive procedures such as artery embolization and more invasive surgical treatment in the form of myomectomy or hysterectomy.

Adenomyosis– uterine adenomyosis is a condition in which the inner of the uterus grows into the muscle wall of the uterus causing heavy and painful menstrual periods. Symptoms of adenomyosis that are different from uterine fibrosis include prolonged menstrual bleeding chronic pelvic pain, and blood clot in the pelvis and legs. We cannot rule out this diagnosis.

Endometriosis- laparoscopy- negative for any endometriosis lesions in the pelvic. Pelvic pain is common among women with endometriosis, is insufficient alone as an indicator of endometriosis (Agarwal, et al., 2019). And chronic pelvic pain can due also to endometriosis.

Endometrial cancer– biopsy is negative for malignancy.

Plan-.

 Management- the patient had been on gonadotropin-releasing hormone agonists as a preoperative treatment to decrease the size of the fibromas, and to decrease blood loss during operative time foe 2 month (DE LA CRUZ & BUCHANAN., 2017).

In a previous visit the option of surgical treatment was discussed, and the patient gave agreement to get a transvaginal hysterectomy done in case that would be needed. The lab work showed that the anemia was not improving and the patient complaining of fatigue, and she feels anxious for no reason.

The patient is scheduled for hysteroscopy without bilateral salpingo-oophorectomy- there are 2 submucous fibroids diameters 8 and 5 cm.                

 

Education

According to (Stovall & Mann, 2021). There are some complication that might occur after surgery, and the patient is educated about them such as

• low-grade fever that usually resolved without treatment.

• constipation that can be controlled with a regimen of stool softeners, dietary fiber, and laxatives.

• Urinary retention- urine can be drained using a catheter until retention resolves within 2448 hours.

• Blood clots- prevention before surgery- compression stockings, pneumatic compression devices.

• Early menopause- due to an interruption in blood flow to the ovaries as a result of removing the uterus.

• After surgery- fluids- IV- and food are generally offered soon after surgery.

Check up with the surgeon 2 weeks after surgery.

 

 

 

 

 

References

Agarwal, S. K., Chapron, C., Giudice, L. C., Laufer, M. R., Leyland, N., Missmer, S. A., … &

         Taylor, H. S. (2019). Clinical diagnosis of endometriosis: a call to action. American

         journal of obstetrics and gynecology, 220(4), 354-e1

Al-Hendy, A., Lukes, A. S., Poindexter III, A. N., Venturella, R., Villarroel, C., Critchley, H. O.

         D., Yulan Li, McKain, L., Ferreira, J. C. A., Langenberg, A. G. M., Wagman, R. B.,

         Stewart, E. A., Poindexter, A. N., 3rd, Li, Y., & Arjona Ferreira, J. C. (2021). Treatment

         of Uterine Fibroid Symptoms with Relugolix Combination Therapy. New England

         Journal of Medicine, 384(7), 630–642.

https://doi.org/10.1056/NEJMoa2008283 

DE LA CRUZ, M. S. D., & BUCHANAN, E. M. (2017). Uterine Fibroids: Diagnosis and

         Treatment. American Family Physician, 95(2), 100–107.

Middelkoop, M.-A., Harmsen, M. J., Manyonda, I., Mara, M., Ruuskanen, A., Daniels, J., Mol,

         B. W. J., Moss, J., Hehenkamp, W. J. K., & Wu, O. (2021). Uterine artery embolization

         versus surgical treatment in patients with symptomatic uterine fibroids: Protocol for a

         systematic review and meta-analysis of individual participant data. European Journal of

Obstetrics & Gynecology & Reproductive Biology, 256, 179–183. https://doi.org/10.1016/j.ejogrb.2020.11.027 

Stovall, T.G & Mann, W, J. (2021). Patient education: Abdominal hysterectomy (Beyond the

         Basics). Retrieved from

https://www.uptodate.com/contents/abdominal-hysterectomy-beyond-the-basics

Wilde, S., & Scott-Barrett, S. (2009). Radiological appearances of uterine fibroids. The Indian

journal of radiology & imaging, 19(3), 222–231.

 https://doi.org/10.4103/0971-3026.54887

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.

• Review the Learning Resources for this week and specifically review the clinical guideline resources specific to your proposed case study.

• 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:

• POST A Focused SOAP NOTE only and describe your case study.  

• Provide a 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 priority in conducting your assessment.

• Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.

• Also, share with your colleagues your experiences as well as what you learned from these experiences.

 

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