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 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
Based on your assigned case study, post a Focused SOAP NOTE with the following:
· 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 first priority in conducting your assessment.
· Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.