Focused SOAP Note-Post Menopausal Bleeding Discussion
Focused SOAP Note-Post Menopausal Bleeding Discussion
Subjective Data
Chief complaint: brown vaginal discharge
History of presenting complaint: Thelma smith is a 58years old African American female presenting with brownish discharge for several days last week. It has no smell and is copious to soak two tampons daily Associating symptoms are itchiness at the vulva and labia, pain and inflammation after intercourse, and post-coital bleeding. Focused SOAP Note-Post Menopausal Bleeding Discussion
Past medical history: the patient has type 2 diabetes on glipizide and metformin. Her last A1C was at 7.5%. She denies hospital admission, blood transfusion, and surgical procedures.
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Reproductive and sexual history: her menarche was at the age of 13years. The last menstrual period was on 25/12/ 2019. Her cycle was regular at 28days with three days of moderate flow. She has never been on any birth control method. She had her first sexual encounter at the age of 20years. She is heterosexual with one partner and engages in vaginal and anal sex at least once a week. She has never been screened for sexually transmitted infections and HIV. In addition, the patient is a G0, having never been able to get pregnant.
Current medication: she takes Glipizide 5mg PO OD and metformin 1000mg PO BD for type 2 diabetes mellitus.
Health maintenance: she is up to date with mammograms and has had a colonoscopy 1 year ago, all normal. Her last pap smear 2 years ago reported a NILM HPV negative, atrophic changes, and no endocervical cells noted.
Objective Data
General examination: the patient is alert and oriented. She seems to be obese. However, she has no pallor, jaundice, lymphadenopathy, or edema.
Vitals: her temperature is 98.1, BP 140/88mmHg, pulse 82 beats per minute, respirations 12. She is 5’6″ inches, 272 lbs, and BMI of 43.90
Abdominal examination: the abdomen is obese, soft, and bowel sounds are present.
Vaginal exam: brownish discharge noted
Cervix: brownish discharge noted coming from the OS. There is no cervical motion tenderness.
Assessment
The patient is 58years old female three years post-menopause. She has brown vaginal discharge, diabetes mellitus type 2, and obesity. Menopause is twelve months of amenorrhea due to hormonal changes. It is a result of the loss of ovarian sensitivity to gonadotrophin stimulation leading to follicular attrition (Santoro, et al, 2021). With time, it leads to the suppression of FSH and LH hormones that stimulates the secretion of estrogen from the ovaries. These hormonal changes lead to weight gain, vaginal dryness, hot flushes, and endometrial atrophy. Upon examination, she has a brown discharge and atrophic changes. Therefore, my differential diagnosis will include vaginal atrophy, endometrial hyperplasia, and atrophic vaginal infection. Focused SOAP Note-Post Menopausal Bleeding Discussion
Vaginal atrophy is characterized by the thinning of the vaginal lining due to decreased production of estrogen hormone. Estrogen hormone maintains the normal size and shape of the genitalia. In vaginal atrophy, the vagina tends to become dry, less flexible, and susceptible to inflammation (Dos Santos, et al, 2021). The presenting symptoms are brown discharge, itchiness, pain and inflammation, redness, and bleeding after sex. The patient has similar symptoms to those of vaginal atrophy. Focused SOAP Note-Post Menopausal Bleeding Discussion
Endometrial hyperplasia is the proliferation of the endometrial lining due to exposure to the estrogen hormone and depletion of the estrogen hormone. Risk factors for endometrial hyperplasia are old age (above 50 years), obesity, null-parity, obesity, diabetes mellitus, and hormone replacement therapy (Singh, G., & Puckett, Y. 2021). It presents with profuse vaginal bleeding and the passing of clots. The patient presents with the risk factors; obesity, diabetes mellitus, null parity, and post-menopause. However, it is not the actual diagnosis because the patient does not have profuse vaginal bleeding.
Atrophic vaginitis is the inflammation of the vaginal walls due to colonization by infectious agents and changes in the vaginal walls (thinning and dryness). It presents with brownish discharge, dryness of the vagina, itchiness, dyspareunia, and post-coital bleeding (Dos Santos, et al, 2021). It is common in post-menopausal patients and has diabetes mellitus. During menopause, there is insufficient production of estrogen hormone. This makes the vaginal walls become thin and lose elasticity. It also alters the acid-base balance thus increasing the prevalence of infection. Diabetes mellitus lowers the patient’s immunity hence increasing the risk for vaginitis. This is the patient’s actual diagnosis. Focused SOAP Note-Post Menopausal Bleeding Discussion
Plan
Diagnostic tests
- Pap smear
- Urine analysis
- Pelvic ultrasound
- Serum hormone testing
Non-pharmacological-Encourage the use of moisturizers to prevent dryness
Pharmacological-Osphena 60mg PO OD
Reflection Note
The experience of assessing this patient was exciting and informative. I have learned about different presenting symptoms in the reproductive system in post-menopausal women. The patient was easy to create rapport with and this made her open up to challenges affecting post-menopausal women. Please use uploaded template and follow directions below. Case Study: Postmenopausal Bleeding 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 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. Focused SOAP Note-Post Menopausal Bleeding Discussion
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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 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. Use your Learning Resources and/or evidence from the literature to support your thinking and perspectives. Focused SOAP Note-Post Menopausal Bleeding Discussion
