Chief Complaint
“I have bloody discharge and pain.”
HPICC
A 43-year-old female with a past medical history of Chlamydia infection comes to visit for bloody vaginal discharge from the last six months. The vaginal discharge is dark red and has a smell. She decided to visit the Doctor because she started having painful intercourse three weeks ago. She started taking ginger tea three times a day recommended by a neighbor, but the beading discharge now is worse.
Medications
Medications: None
Herbals: Ginger tea daily starting two weeks ago.
PMH
Allergies: The patient does not suffer from any environmental, food, or drugs allergies
Medication Intolerances: NKDA
Chronic Illnesses/ Major trauma: None
Chlamydia treated ten years ago
LMP two weeks ago G3 P3. The patient denies having major traumas.
PAP SMEAR 2010 Normal
Family History
Father died of stomach cancer at 45. Negative for hypertension, cancer, heart disease, diabetes, tuberculosis, other medical illnesses.
Mother negative for diabetes, cancer, hypertension, heart disease, tuberculosis, other medical illnesses
Social History
The patient is an immigrant from central Africa. She took a basic test to enter the USA two years ago. Socially not active, she stays at home all day and only goes to the supermarket and church every week. She is living with her husband’s parents and her two children, aged 14 and 12. She does not drink alcohol and does not smoke or use any drugs. She does not visit doctors. No pap smear. She is sexually active.
ROS
General
The patient is feeling poor energy without strength. She lost some weight 8 to 10 pounds in the last six months, fever, and night sweats. She lost her appetite. Denied fever, headache, or dizziness.
Skin
No rash, lesions bruising.
Eyes
The patient denies blurring, visual changes
Gastrointestinal
Abdominal distention and lost appetite too much. No abdominal pain, diarrhea reflux.
Ears
No ear pain, ringing in ears, etc. There are no reports of ear traumas or hearing loss.
Nose/Mouth/Throat
Denies any sore throat, oral cavity’s complaints.
Breast
Denies feeling lumps, bumps, or changes.
Heme /Lymph/Endo
She denies having a transfusion, extreme sweating, changes in her appetite, lumps bleeding, or equipoises. Intermittent vaginal bleeding for six months.
Cardiovascular
She denies chest pain, edema, orthopnea, palpitations.
Respiratory
She has shortness of breath when walking fast, no cough, congestion, wheezing, hemoptysis, or dyspnea.
Genitourinary / Gynecological
Mild discomfort in her pelvic area that is worse when doing sexual intercourse. She found this two weeks ago sharp pressure above the pubis when doing sexual intercourse.
History of STD 10 years ago.
Musculoskeletal
No joint pain, muscular pain, or weakness.
Neurological
Denies spontaneous episodes of weakness, memory loss.
Psychiatric
The patient did not report having depression, sleeping disorder, suicidal attempts.
Objective
Weight: 151lbs.
BMI: 28.5.
Temp: 97.1F tympanic
BP: 124/70 right arm, sitting.
Height: 5’1”
Pulse:90 x min
Resp:16 x min.
Oxy Sat 99%
General Appearance
Female. Not in distress, cooperative but shy, answers willingly and appropriately.
Skin
The patient’s skin is warm, dark, clean. No petechiae ecchymosis or moles were found.
HEENT
Head is norm-cephalic, is symmetric, no lesions found. Her hair is distributed in accordance with her sex and age. No tenderness
Eyes show no abnormal signs. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The sclera is clear.
Ears: Symmetric, normal hearing tympanic positive light reflex.
Nose: No visible septum deviation, fine and pink mucosa, no polyps.
Neck: Symmetric, no nodes, no thyromegaly.
No gingival edema or blleding.
Cardiovascular
No extra sounds are discovered during the patient’s investigation. The rate and rhythm are regular. Capillary refill – 1.7 seconds. There is no edema.
Respiratory
The patient’s chest wall is symmetric expansion. She demonstrates regular respirations. There are no problems with breathing.
Gastrointestinal
The patient’s abdomen is obese, with some striae soft. Bowel sound present. No epigastric tenderness to deep palpation. No mases. Active in all quadrants.
Breast
Symmetric breast no masses no edema or erythema.
Genitourinary
External exam: Vulva inspection with no edema, pubic hair normal for age and sex. The speculum found vaginal walls cover with blood and mucus os closed, cervical bleeding mass extending to the uterine body at 10, tender to palpation. A biopsy was taken. Suprapubic tenderness when performing bimanual palpation. The rectal exam demonstrates the pain, masses, and uterine mass, with no signs of trauma. No bleeding signs were found. A urine sample was taken for in site exam.
Musculoskeletal
Full range of motion, locomotor apparatus is fine. Muscular strength 5/5 four limbs.
Neurological
Speech is clear, responds to all answers in an appropriate way. Demonstrates an appropriate level of cognitive activity. DTR patellar reflexes are intact 2/2 patellar. Balance is stable.
Psychiatric
The patient does not keep eye contact. Speech is clear. Understands all questions. No visible signs of mental disorders. The family history also does not contain any records of this sort.
Lab Tests
Several lab tests are needed to reveal what is wrong with the patient. First of all, a range of general tests should be conducted when a client is admitted to a hospital. Mainly, they deal with the analysis of blood and urine.
The most commonly conducted test is a complete blood count. It provides an opportunity to discuss the patient’s state of health and can reveal the presence of health issues, such as infection.
In addition to that, urinalysis allows medical staff to identify various signs of poor health. For example, it shows the presence of different infections, disorders, and liver problems (“Urinalysis,” 2016).
When these tests are done, additional specific lab tests are needed. They should be focused on the patient’s condition and her chief complaint.
Special Tests
In this case, lab tests should be connected with bloody discharge and pain. In particular, all of them should be able to identify health issues that may cause these problems.
- Pregnancy test. Rather often, issues associated with pregnancy have the same symptoms as those mentioned by the patient. This test will provide a doctor with an opportunity to refute or prove the diagnosis.
- Transvaginal ultrasound. It allows identifying abnormalities that cause discomfort in the pelvic area and bleeding.
- Sonohysterogram. Ultrasound can be used to check if the mentioned symptoms are caused by uterine polyps or fibroids (Healthwise, 2015).
- Biopsy. It may be needed to check the condition and functioning of the endometrium. Moreover, it can be used for the identification of abnormal cervical cells.
- Visual examination. It allows looking inside the bladder and finding out issues.
- Pap test. It will provide an opportunity to identify abnormalities in the cervix. A doctor will scrape cells and examine them to detect those that show changes (Stoppler & Shiel, 2017). They can reveal the presence of cancer or the risk of it.
- Imaging tests. They can be needed if cervical cancer is identified in order to determine what organs are also affected. Thus, a particular stage can be revealed. For this purpose, a doctor may use x-rays or magnetic resonance imaging, etc.
Assessment Findings and Plan
Differential Diagnoses
Chlamydia
This disease is sexually transmitted and can be present in the patient as she is sexually active. The patient has already suffered from this disease that is why she might be likely to face it again. Her symptoms are associated with this health issue, as she experiences vaginal bleeding, and her discharge is painful (Johnson, 2015). Moreover, she reports discomfort in the pelvic area that worsens when having sex.
Ectopic pregnancy
It is already known, the patient is sexually active. Regardless of the use of contraceptives, there is a possibility of her being pregnant. Of course, in a normal situation mentioned, adverse symptoms would not be faced. But if she has an ectopic pregnancy, her condition can be explained by this diagnosis (Johnson, 2017). The patient experiences pain and vaginal bleeding.
Cervical cancer
This diagnosis aligned with all patient’s symptoms, such as bleeding, pain, discomfort during intercourse, and problems with discharge. In addition to that, her father had cancer which increases her chances of having this problem. This conclusion can be made only after the results of a Pap test are received (abnormal cells are found) (Mayo Clinic Staff, 2017). Being supported by a biopsy, cervical cancer is likely to be the final diagnosis for the patient.
Treatment Plan and Follow Up
Treatment of cervical cancer will be presented in several ways. First of all, the patient will receive a recommendation to have surgery, during which affected tissues will be removed, including pelvic lymph nodes and uterus. There might be a necessity to remove ovaries and fallopian tubes as well. Further, chemotherapy will be provided and/or radiation therapy (Stoppler & Shiel, 2017).
When the remission is achieved, follow-up appointments and tests are to be planed. Every few months, the patient should be checked for any associated problems and complications (“Cervical cancer: Follow up,” 2017). In this way, attention should be paid not only to the healing process but also to the possibility of the re-occurrence of cancer.
Self-Assessment
The patient should be encouraged to conduct self-assessment in order to ensure that she is in good condition after the treatment. Moreover, such practices will provide her with an opportunity to receive timely healthcare assistance if it is needed. In this framework, it is vital to educate her on the sexually-transmitted diseases, their causes, and symptoms to minimalize future risks. The peculiarities of her condition should also be discussed, including all possible symptoms of cervical cancer. Enormous attention should be paid to the procedure of self-assessment, which presupposes the comparison of a healthy condition with a problematic one. Healthcare professionals should identify those tools that may be needed during the cervical examination, such as a mirror and flashlight. The necessity to obtain the speculum should also be discussed, but it requires additional education regarding its usage. The patient should get to know how to sit to prevent injuries and discomfort during self-assessment. She should pay attention to the color of her cervix and its structure. The amount and consistency of discharge should also be compared with normal. Moreover, its odor should be considered. Finally, any discomfort and pain should be mentioned and reported to healthcare professionals.
References
Cervical cancer: Follow up. (2017). Web.
Healthwise. (2015). Abnormal uterine bleeding. Web.
Johnson, T. (2015). Chlamydia. Web.
Johnson, T. (2017). What to know about ectopic pregnancy. Web.
Mayo Clinic Staff. (2017). Cervical cancer. Web.
Stoppler, M., & Shiel, W. (2017). Cervical cancer. Web.
Urinalysis. (2016). Web.