NRNP 6552 Common Gynecologic Conditions, Part 1

NRNP 6552 Common Gynecologic Conditions, Part 1

Week 4: Case Study 1- Episodic/Focused SOAP Note

Patient Information:

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

S.

CC (chief complaint): “brown discharge to pink spotting”

HPI: T.S., a 58-year-old African American woman, comes into the clinic complaining of brown discharge to pink spotting for many days last week. The patient’s medical record indicates a noteworthy medical history of type 2 diabetes, which has been partially managed through the use of glipizide and metformin, as evidenced by a recent A1C reading of 7.5. She has a nulliparous obstetric history, indicating that she has never experienced a pregnancy. The patient is current with regards to mammograms and underwent a colonoscopy one year prior, with results indicating no abnormalities. The patient’s pap smear history is within normal limits, with her most recent pap smear conducted two years ago indicating a negative for intraepithelial lesion or malignancy (NILM) result. The results indicate a lack of HPV presence, the presence of atrophic changes, and the absence of endocervical cells.

Location: vaginal

Onset: last week

Character: brown discharge to pink spotting

Associated signs and symptoms: none

Timing: none

Exacerbating/relieving factors: none

Severity: 6/10 pain scale

Current Medications: Glipizide 5 mg once a day and metformin 500 mg twice daily

Allergies: No known sensitivities to substances, foods, or environments.

PMHx:

Past Medical History: type 2 diabetes which is well managed with medication

Immunizations: Vaccination records are current.

Soc & Substance Hx: The patient is married but has never given birth and has no children. She shares a two-story, three-bedroom single-family home with her hubby. prohibits using tobacco, using e-cigarettes, vaping, or being around others who do. denies engaging in illicit or recreational drug use. denies having a drink. She says she is now a banker. She professes to be a devout Christian and puts a lot of importance on her spiritual health. She says she has a huge network of family, friends, and churchgoers. She eats three meals a day and says she tries her hardest. She naps for six to eight hours. She usually works out by taking the dog for a walk in the evening.

Fam Hx: Her father has diabetes and is 83 years old. Two years ago, her mother’s cervical cancer took her life.

Surgical Hx: None

Mental Hx: denies sadness or anxiety. denies having ever used self-harm or had suicidal or homicidal thoughts.

Violence Hx: denies any safety worries or concerns

Reproductive Hx: GYN History: LMP eight years ago; most recent Pap test was two years ago; results were WNL; one partner; and no use of birth control; straight. OB History: Gravida: 0 Para: 0

ROS:

GENERAL: The patient seemed healthy, and active, and denied having gained or lost weight.

HEENT: Eyes: denies any loss of vision, double vision, impaired vision, or yellow sclera. Denies hearing loss, sniffles, congested nose, runny nose, or hoarseness.

SKIN: denies having a rash or irritation.

CARDIOVASCULAR: denies feeling pressure, pain, or discomfort in the chest. No edema or palpitations.

RESPIRATORY: denies having a cough, sputum, or shortness of breath.

GASTROINTESTINAL: denies having anorexia, motion sickness, or diarrhea. neither blood nor stomach discomfort.

NEUROLOGICAL: denies experiencing headaches, vertigo, syncope, paralysis, ataxia, or tingling in the extremities. No modification to bladder or bowel control.

MUSCULOSKELETAL: denies experiencing stiffness, joint discomfort, back pain, or muscular pain.

HEMATOLOGIC: denies bruising, bleeding, or anemia.

LYMPHATICS: denies having larger nodes. denies having had a splenectomy.

PSYCHIATRIC: denies having a history of anxiety or depression.

ENDOCRINOLOGIC: reports a type 2 diabetes history. denies having a cold or heat sensitivity or sweating. No polydipsia or polyuria.

GENITOURINARY/REPRODUCTIVE: complaints of brown discharge to pink spots last week, lasting for many days. LMP eight years back, last Pap test two years ago, resulting in WNL, one partner, no birth control use, heterosexual. OB History: Gravida: 0 Para: 0

ALLERGIES: denies having ever had rhinitis, hives, asthma, or eczema.

O.

Physical exam:

Vital signs: Temperature: 98.1°F, blood pressure: 140/88, pulse: 82, and respirations: 12. She is 272 pounds and 5’6″. (BMI 43.90).

Focused exam:

General: focused and awake. seemed to be well-groomed. The patient does not seem to be experiencing any immediate discomfort.

Abdomen: soft, overweight, and bowel sound-positive

VVBSU:  observed brown discharge,

Cervix: No cervical motion pain and brown blood were seen originating from the os

Uterus: being unable to evaluate owing to the physical habit

Adnexa: owing to bodily habit, impossible to evaluate

Diagnostic results: A1C last 7.5. Her Pap history is normal, and her most recent Pap revealed a NILM two years ago. Atrophic alterations, no endocervical cells, and HPV negative.

A.

Primary and Differential Diagnoses

  1. Endometrial or Vaginal Atrophy: Brown spotting after menopause, as seen by the patient, is often an indication that blood has mixed with the discharge. According to studies, postmenopausal women often have vaginal atrophy, which may cause brown spotting and itching (Nappi et al., 2020).
  2. Endometrial polyps: Brown discharge seen before and after menstruation is another sign of polyps (Tanos, 2019). Painless polyps do not exist.
  3. UTI: Diabetic patients, like the one mentioned above, often get UTIs. In addition to the acute UTI symptoms, persistent UTIs may result in spotting, blood in the urine, or discharge (Wasserman & Rubin, 2023).

Primary diagnosis: Endometrial or Vaginal Atrophy

Additional Questions:

  1. What additional symptoms do you manifest besides the transition from pink discharge to brown spotting? This inquiry will facilitate the acquisition of additional data to bolster the primary diagnosis. Elia et al. (2019) have identified several symptoms that are associated with the condition, including vaginal dryness, itchiness, burning during urination, and recurrent urinary tract infections.
  2. What was the date of your most recent menstrual cycle? The inquiry in question is intended to ascertain whether the symptoms exhibited by the patient are attributable to menopause, as posited by Elia et al. (2019).
  3. Have you engaged in sexual activity recently? This inquiry will aid in ascertaining whether the individual’s symptoms are attributable to a sexually transmitted infection/disease.

The lining of the patient’s vagina becomes drier and thinner in vaginal atrophy. To corroborate this diagnosis, the inquiries will concentrate on symptoms like itchiness, burning, and discomfort during sex, among others (Nappi et al., 2020). Urinary tract issues such as urinary incontinence and UTIs are also a part of this illness.

Diagnostic tests: A Pap test,  ultrasound, urine sample, vaginal pH (acid test), and testing for vaginal infection will all be required to establish the main diagnosis and exclude the differentials (Nappi et al., 2019).

Treatment options: Only dehydroepiandrosterone (DHEA) and estrogen therapy are hormone treatments for vaginal atrophy (Pinkerton, 2021).

Health Promotion: Regular sexual activity improves vaginal tissue blood flow, which helps prevent vaginal atrophy (Nappi et al., 2019).

Patient Education: admonish the patient to stay away from vaginal irritants including douching, dye, shampoo, and cologne (Nappi et al., 2019).

Referrals: The patient needs to see a gynecologist for further assessment and treatment.

Follow-up: After two weeks, the patient must return to the clinic for an assessment of the effectiveness of the therapy.

Reflection: The material presented for the assigned case study is rather scant, supporting the main vaginal atrophy diagnosis. Brown spotting is a frequent symptom of menopause and may be brought on by several medical issues. However, DHEA is the most effective kind of therapy if the patient’s vaginal atrophy is proven (Pinkerton, 2021). To improve the patient’s general health and well-being, it is also important to encourage her to consume a good diet and exercise often. One of the key preventative methods for vaginal atrophy has also been suggested: regular sexual activity.

 

 

References

Elia, D., Gambacciani, M., Berreni, N., Bohbot, J. M., Druckmann, R., Geoffrion, H., Haab, F., Heiss, N., Rygaloff, N., & Russo, E. (2019). Genitourinary syndrome of menopause (GSM) and laser VEL: a review. Hormone Molecular Biology and Clinical Investigation, 0(0). https://doi.org/10.1515/hmbci-2019-0024

Nappi, R. E., Di Carlo, C., Cucinella, L., & Gambacciani, M. (2020). Viewing symptoms associated with Vulvovaginal Atrophy (VVA)/Genitourinary syndrome of menopause (GSM) through the estro-androgenic lens – Cluster analysis of a web-based Italian survey among women over 40. Maturitas, 140, 72–79. https://doi.org/10.1016/j.maturitas.2020.06.018

Nappi, R. E., Martini, E., Cucinella, L., Martella, S., Tiranini, L., Inzoli, A., Brambilla, E., Bosoni, D., Cassani, C., & Gardella, B. (2019). Addressing Vulvovaginal Atrophy (VVA)/Genitourinary Syndrome of Menopause (GSM) for Healthy Aging in Women. Frontiers in Endocrinology, 10. https://doi.org/10.3389/fendo.2019.00561

Pinkerton, J. V. (2021). Selective Estrogen Receptor Modulators in Gynecology Practice. Clinical Obstetrics & Gynecology, 64(4), 803–812. https://doi.org/10.1097/grf.0000000000000647

Tanos, V. (2019). Management of endometrial polyps. Women Health Care and Issues, 2(1), 01–07. https://doi.org/10.31579/2642-9756/004

Wasserman, M. C., & Rubin, R. S. (2023). Urologic view in the management of genitourinary syndrome of menopause. Climacteric, 1–7. https://doi.org/10.1080/13697137.2023.2202811

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COMMON GYNECOLOGIC CONDITIONS, PART 1

Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, and diagnostic approaches, as well as to the development of treatment plans.

For this Case Study Discussion, you will once again review a case study scenario to obtain information related to a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop treatment and management plans.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

 

LEARNING RESOURCES

Required Readings

  • Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.
    • Chapter 17, “Breast Conditions” (pp. 337-349)
    • Chapter 18, “Alterations in Sexual Function” (pp. 353-364)
    • Chapter 20, “Infertility” (pp. 383-398)
    • Chapter 21, “Gynecologic Infections” (pp. 401-432)
    • Chapter 22, “Sexually Transmitted Infections” (pp. 437-466)

CLINICAL GUIDELINE RESOURCES

As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for CDC – zika in pregnancy).

Optional Resources

Note: In Weeks 1-10, these resources are optional for your review. In Week 11, you will be required to review each of the PowerPoint slides from the text Gynecologic Health Care (4th ed.).

To prepare:

  • By Day 1 of this week, you will be assigned to a specific case study scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
  • Review the Learning Resources for this week and specifically review the clinical guideline resources specific to your assigned 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. Please post your FOCUSED SOAP note. This information will help you develop your differential diagnosis and additional questions

Case Study 1

Thelma Smith is a 58-year-old African American female who presents to the office with the complaint of brown discharge to pink spotting 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 G0P0, having never been able to get pregnant. She is up to date with mammograms and has had a colonoscopy 1 year ago, all normal. Her pap history is normal with her last pap 2 years ago reported 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

BY DAY 3

Please post your FOCUSED SOAP NOTE and post your primary diagnosis. Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)

Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations. Your primary diagnosis, additional questions, and types of symptoms are what this assignment and grading is focused on. Your critical thinking for this assignment

Read a selection of your colleagues’ responses.

 

BY DAY 6

Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of diagnostic tests you would recommend and explain your reasoning. Use your Learning Resources and/or evidence from the literature to support your position.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!

 

NRNP_6552_Week4_Case_Study_Discussion_Rubric

NRNP_6552_Week4_Case_Study_Discussion_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeMain Posting:Response to the case study discussion questions includes appropriate diagnoses with explanations of appropriate diagnostic tests and treatment options as directed, is based on evidence-based research where appropriate, and is incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources.
44 to >39.16 ptsExcellent Point range: 90–100

Thoroughly responds to the discussion question(s)… Post includes appropriate diagnoses including explanations of appropriate diagnostic tests and treatment options… Incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources, with no less than 75% of post the post having exceptional depth and breadth… Supported by at least 3 current credible sources.

 39.16 to >34.76 ptsGood Point range: 80–89

Responds to most of the discussion question(s)… Post includes appropriate diagnoses with explanations of appropriate diagnostic tests and treatment options… Somewhat incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources with no less than 50% of the post having exceptional depth and breadth… Supported by at least 3 credible references.

 34.76 to >30.36 ptsFair Point range: 70–79

Responds to some of the discussion question(s)… Post contains incomplete or vague diagnoses or explanations of appropriate diagnostic tests and treatment options… Is somewhat lacking in synthesis of knowledge gained from the course readings for the module and current credible sources… Post is cited with fewer than 2 credible references.

 30.36 to >0 ptsPoorPoint range: 0–69

Does not respond to the discussion question(s)… Post contains incomplete diagnoses or explanations of appropriate diagnostic tests and treatment options, or diagnoses and/or explanations are missing… Lacks synthesis gained from the course readings for the module and current credible sources… Contains only 1 or no credible references.
44 pts
This criterion is linked to a Learning OutcomeMain Posting:Writing
6 to >5.34 ptsExcellent Point range: 90–100

Written clearly and concisely… Contains no grammatical or spelling errors… Further adheres to current APA manual writing rules and style.

 5.34 to >4.74 ptsGood Point range: 80–89

Written concisely… May contain one to two grammatical or spelling errors… Adheres to current APA manual writing rules and style.

 4.74 to >4.14 ptsFair Point range: 70–79

Written somewhat concisely… May contain more than two spelling or grammatical errors… Contains some APA formatting errors.

 4.14 to >0 ptsPoor Point range: 0–69

Not written clearly or concisely… Contains more than two spelling or grammatical errors… Does not adhere to current APA manual writing rules and style.
6 pts
This criterion is linked to a Learning OutcomeMain Posting:Timely and full participation
10 to >8.9 ptsExcellent Point range: 90–100

Meets requirements for timely, full, and active participation… Posts main discussion by due date.

 8.9 to >7.9 ptsGood Point range: 80–89

Posts main discussion by due date… Meets requirements for full participation.

 7.9 to >6.9 ptsFair Point range: 70–79

Posts main discussion by due date.

 6.9 to >0 ptsPoor Point range: 0–69

Does not meet requirements for full participation… Does not post main discussion by due date.
10 pts
This criterion is linked to a Learning OutcomeFirst Response:Post to colleague’s main post that is reflective and justified with credible sources.
9 to >8.01 ptsExcellent Point range: 90–100

Response exhibits critical thinking and application to practice settings… Responds to questions posed by faculty… The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

 8.01 to >7.11 ptsGood Point range: 80–89

Response has some depth and may exhibit critical thinking or application to practice setting.

 7.11 to >6.21 ptsFairPoint range: 70–79

Response is on topic, may have some depth.

 6.21 to >0 ptsPoor Point range: 0–69

Response may not be on topic, lacks depth.
9 pts
This criterion is linked to a Learning OutcomeFirst Response: Writing
6 to >5.34 ptsExcellent Point range: 90–100

Communication is professional and respectful to colleagues… Response to faculty questions are fully answered, if posed… Provides clear, concise opinions and ideas that are supported by two or more credible sources… Response is effectively written in Standard, Edited English.

 5.34 to >4.74 ptsGood Point range: 80–89

Communication is mostly professional and respectful to colleagues… Response to faculty questions are mostly answered, if posed… Provides opinions and ideas that are supported by few credible sources… Response is written in Standard, Edited English.

 4.74 to >4.14 ptsFair Point range: 70–79

Response posed in the discussion may lack effective professional communication… Response to faculty questions are somewhat answered, if posed… Few or no credible sources are cited.

 4.14 to >0 ptsPoor Point range: 0–69

Responses posted in the discussion lack effective communication… Response to faculty questions are missing… No credible sources are cited.
6 pts
This criterion is linked to a Learning OutcomeFirst Response:Timely and full participation
5 to >4.45 ptsExcellent Point range: 90–100

Meets requirements for timely, full, and active participation… Posts by due date.

 4.45 to >3.95 ptsGood Point range: 80–89

Meets requirements for full participation… Posts by due date.

 3.95 to >3.45 ptsFair Point range: 70–79

Posts by due date.

 3.45 to >0 ptsPoor Point range: 0–69

Does not meet requirements for full participation… Does not post by due date.
5 pts
This criterion is linked to a Learning OutcomeSecond Response:Post to colleague’s main post that is reflective and justified with credible sources.
9 to >8.01 ptsExcellent Point range: 90–100

Response exhibits critical thinking and application to practice settings… Responds to questions posed by faculty… The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

 8.01 to >7.11 ptsGood Point range: 80–89

Response has some depth and may exhibit critical thinking or application to practice setting.

 7.11 to >6.21 ptsFair Point range: 70–79

Response is on topic, may have some depth.

 6.21 to >0 ptsPoor Point range: 0–69

Response may not be on topic, lacks depth.
9 pts
This criterion is linked to a Learning OutcomeSecond Response:Writing
6 to >5.34 ptsExcellent Point range: 90–100

Communication is professional and respectful to colleagues… Response to faculty questions are fully answered, if posed… Provides clear, concise opinions and ideas that are supported by two or more credible sources… Response is effectively written in Standard, Edited English.

 5.34 to >4.74 ptsGood Point range: 80–89

Communication is mostly professional and respectful to colleagues… Response to faculty questions are mostly answered, if posed… Provides opinions and ideas that are supported by few credible sources… Response is written in Standard, Edited English.

 4.74 to >4.14 ptsFair Point range: 70–79

Response posed in the discussion may lack effective professional communication… Response to faculty questions are somewhat answered, if posed… Few or no credible sources are cited.

 4.14 to >0 ptsPoor Point range: 0–69

Responses posted in the discussion lack effective communication… Response to faculty questions are missing… No credible sources are cited.
6 pts
This criterion is linked to a Learning OutcomeSecond Response:Timely and full participation
5 to >4.45 ptsExcellent Point range: 90–100

Meets requirements for timely, full, and active participation… Posts by due date.

 4.45 to >3.95 ptsGood Point range: 80–89

Meets requirements for full participation… Posts by due date.

 3.95 to >3.45 ptsFair Point range: 70–79

Posts by due date.

 3.45 to >0 ptsPoor Point range: 0–69

Does not meet requirements for full participation… Does not post by due date.
5 pts
Total Points: 100

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