student example clinical

Name:

NR

Date: 05/25/2017

Time: 1500

Insurance Type: (private, Medicaid, none)

Age: 61

Sex: Female

SUBJECTIVE

CC: 

“I have been experiencing irregular bleeding for three weeks.”

HPI: 

Mrs. N.R. is a 61-year-old white female G1T1A0 who presents to the Ob/Gyn clinic today with the chief complaint of irregular vaginal bleeding for three weeks. The patient appears to be in no distress. On 05/24/2017, she went to her primary care provider who has now referred her to this clinic. She states that she first noticed these symptoms when she was using the bathroom at her daughter’s house. She is very concerned because her LMP was six years ago at age 55. She describes her vaginal bleeding as “spotting, ” and she is now wearing one to two feminine panty liners per day. Mrs. N.R. claims the spotting is at times bright red in color and sometimes brown in color. She is unaware of any actions that aggravate or relieves her symptoms. She reports no abdominal pain or cramping. She rates her symptoms 1/10. The spotting is intermittent. Mrs. N.R. claims that her symptoms may last for a few minutes or may last a few hours. She reports the spotting develops throughout the day and night. She also reports intentionally losing 80 pounds within the past two years. Her original weight was 420 lbs, and her current weight is 339 lbs. She is losing her weight through diet by eliminating carbs and consuming more vegetables and lean meats. The patient and her husband have not been sexually active for the past 15 years. Her last pap smear was in February 2015, and it was negative. She claims she has never been diagnosed with an abnormal pap smear. Her last routine mammogram was in February 2015. The patient has an HMO insurance plan. She and the office staff claims that Human, the insurance company, must make the approval for diagnostic testing before any procedures can be performed.

Patient provided the HPI as follows:
O- Onset of symptoms started three weeks ago
L- Vaginal
D- Symptoms are intermittent and has lasted three weeks.
C- Reports spotting and sometimes she notices bright red in color and at other times brown in color
A- Nothing aggravates or alleviates her symptoms
R- Reports no abdominal pain or cramping
T- Spotting occurs the morning, day, and night.
T- No treatments so far.
S- Rates symptoms 1/10.
All women who live past the age of 50 will experience menopause. The final stage of reproduction in a female’s life is menopause. Menopause is defined as amenorrhea following 12 months after the females last menstrual cycle (Buttaro, Trybulski, Bailey, and Sandberg-Cook, 2013). The practitioner needs to recognize that postmenopausal spotting or bleeding is considered to be not normal (Buttaro et al., 2013). An encounter with a female who presents abnormal bleeding after menopause should entail a complete history and physical examination, laboratory examination, and treatment plan (Hawkins, Roberto-Nichols, and Stanley-Haney, 2016). Based on these recommendations, a comprehensive history was taken, the patient received a complete physical exam, a CBC was ordered to rule out anemia, and endometrial biopsy is ordered to rule out endometrial cancer. 

Medications:

-Lisinopril 20 mg tab by mouth tab by mouth once daily- For hypertension (diagnosed 1991)

Furosemide 40 mg tab by mouth once daily- For hypertension (diagnosed in 1991)

-Citalopram 20 mg tab by mouth once daily- For depression (diagnosed in 1995)

-Levothyroxine 200 mcg tab by mouth once daily- For hypothyroidism (diagnosed in 2001)

-Metformin 1000 mg tab by mouth once daily- For type 2 diabetes mellitus (diagnosed in 1991)

-Glimepiride 4 mg tab by mouth once daily in the am with meal- For type 2 diabetes mellitus (diagnosed in 1991)

-Omeprazole 20 mg tab by mouth once daily in the am- For Gastroesophageal Reflux Disease (GERD) diagnosed in 1989

PMH

Allergies:

No medication, food, environmental, or latex

Medication Intolerances: None

Chronic Illnesses/Major traumas (and year diagnosed)

 -Essential (primary) hypertension

-Major depressive disorder

-Hypothyroidism

-Gastro-esophageal reflux disease without esophagitis

-Type 2 diabetes mellitus without complications

-Morbid obesity due to excessive calories

Hospitalizations/Surgeries

 The patient received a right total knee placement during the year of 2009. The patient had her tonsils removed at the age of 6. 

Family History

Mother: Uncontrolled hypertension, type 2 diabetes mellitus, hyperlipidemia, breast cancer, GERD, morbid obesity, and hypothyroidism. Deceased at age 68.

Father: Uncontrolled hypertension, type 2 diabetes mellitus, hyperlipidemia, alcoholism, esophageal cancer. Deceased at age 57.

Paternal GM: History is unknown. The patient’s mother did not have a relationship with the paternal GM.

Paternal GF: Is deceased, age is unknown. Heavy smoker and Lung Cancer.

Sister: Age is 58. Hypertension, obesity, type 2 DM.

Sister: Age 56. Hypertension, hyperlipidemia, and Type 2 diabetes mellitus.

Daughter: Age 45. Obese and hypertension.

Social History

Education: General Education Diploma

Occupation: Retired. Employed as a gaffer for 22 years. Prior to working as a glassblower, the patient worked in the retail industry. The patient currently volunteers at Blake Hospital.

Current living situation: Lives with husband in a second story apartment. Their daughter lives within Bradenton and visits her mother and father on the weekends.

Substance use/abuse: Denies substance use/abuse

ETOH: Drinks one glass of wine on Friday and Saturday nights.

Tobacco Use: 24 pack year smoking history. Ceased smoking 21 years ago.

Safety Status: She always wears a seatbelt when riding or operating a motor vehicle. Home is safe and free of emotional and physical abuse.

ROS

General

Reports intentional weight loss of 80 pounds. She denies fevers, or a decrease in energy levels.  

Cardiovascular

Reports hypertension. Denies chest pain, palpitations, hair loss on legs, orthopnea, paroxysmal nocturnal dyspnea, and dyspnea on exertion.   

Skin

Denies rashes, bruising, cuts on the skin, abnormal lesions, or any changes in moles.   

Respiratory 

Denies cough and wheezing, substernal chest pain and SOB.

Eyes

 Reports wearing corrective lenses for vision. She denies eye pain or sudden vision changes. 

-Patient reports her last eye exam was 09/2016.

Gastrointestinal

Denies abdominal pain, bloating and nausea, diarrhea, constipation, and bloody stools.  

Ears

Denies ear impaction, ear fullness, ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Denies frequency, any urgency, burning, and change of color in urine.

Denies vaginal douching.

She reports menarche at age 10.

Not sexually active with husband for 15 years. Reports last LMP age 55. 

Last Pap: February 2015

Last Mammogram: February 2015

Nose/Mouth/Throat

The patient denies sinus pain, postnasal drip, and yellow nasal discharge, dental disease or throat pain.

Musculoskeletal

Reports bilateral knee pain and muscle stiffness. Denies restricted range of motion.

Breast

Reports monthly self-breast exams. Denies breast changes, lumps, and nipple discharge.

Neurological

Denies syncope, weakness, black out spells, and parenthesis.

Heme/Lymph/Endo

The patient denies easily bruising, blood transfusions, night sweats, increased thirst or heat and cold intolerance.

Psychiatric

Admits to depression and is well controlled with Citalopram. Denies anxiety, sleeping difficulties, and suicidal ideation.

OBJECTIVE (Document in the IPPA format (except GI)

Weight 339   BMI 58.2

Temp 97.9

BP 136/84

Height 5’4”

Pulse 86

Resp 16

General Appearance

Mrs. N.R. is a healthy-appearing 20-year-old female who appears to be in no distress. She is alert and oriented x 4 and answers questions appropriately. She is well developed and well nourished. She is dressed in clean pink top, black pants and black sandals.

The skin is pink, dry and intact. Skin is appropriate for her Caucasian ethnicity. Temperature is warm to palpation. No rashes, bruising, lacerations, or lesions noted.

HEENT

Head is normocephalic, atraumatic and without lesions. The hair is evenly distributed. Eyes:  PERRL. EOMs intact. No conjunctival or scleral injection. Ears: external canals are patent. Bilateral TMs pearly grey; landmarks easily visualized. Nose: Nasal mucosa is pink; normal turbinates. Neck: Supple. Full ROM; no cervical lymphadenopathy or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous. There is some dental decay is noted on the right upper first molar and right upper second molar.

Heart is RRR with S1 and S2 present. No murmurs, gallops, or rubs. Capillary refill is + 2. No edema noted. Pulses + 3 without.

Respiratory

Chest wall is symmetrical. Respirations are regular and easy. There is no cough present. No hoarseness is present when patient is speaking. Lungs sounds are clear to auscultation, no crackles, wheezes, rhonchi, stridor, or plural rubs.

Abdomen is obese. Bowel sounds are present in all four quadrants with auscultation. There is no guarding and rebound tenderness noted. No masses noted. No hepatosplenomegaly noted. 

Bilateral breast are symmetrical. Nipples are equally round and no discharge is noted. With palpitation the both breast are free from masses, lumps, and tenderness. No swollen or palpable axillary lymph nodes noted.

Genitourinary

Bladder is non-distended and no CVA tenderness noted. External genitalia reveal minimal pubic hair. Skin color is consistent with the body’s pigmentations. There is a small amount of red blood located on the labia minora and vaginal opening. The vaginal examination is performed with a Pederson speculum and reveals pink mucosa, no gross lesions, scant opaque discharge, scant red blood, no unusual odor, and no cervical lesions. Bimanual examination reveals no adnexa pain or masses. Uterus is anteverted. Ovaries are non-palpable. No bladder distention noted with bimanual examination. Rectal inspection reveals no masses or external hemorrhoids.

Full ROM noted as seen when patient ambulates from waiting area to exam room.

Neurological

Speech is clear. Balance and gait are stable.

The patient is oriented to person, place, and time. Her speech is clear. Thought process is coherent. Maintains eye contact with conversation. She does appear to be in no distress.

Lab Tests (Labs ordered for 05/25/2017)

CBC-Pending

CMP- Pending

TSH-1.9

A1c-9.0

Special Tests:

Endometrial biopsy and pap smear (Pending due to insurance approval)

Diagnosis

 Differential Diagnoses

· 1- Polyp of cervix uteri (N841)- A cervical polyp can be considered one differential diagnosis. In general, most cervical polyps are asymptomatic and they are usually discovered during a gynecological exam. Cervical polyps resemble pink spongy lesions whose stalks prolapse through the cervical canal (Schuiling & Likis, 2017). The symptoms associated with cervical polyps include spotting after exercising, vaginal douching, and sexual intercourse (Schuiling & Likis, 2017). Endocervical polyps are frequently seen in the endocervical canal are often associated with premenopausal women (Schuiling & Likis, 2017). While examining the patient, the student and preceptor noted no cervical lesions. Also, Mrs. N.R. denies cervical douching or having sexual intercourse; therefore, cervical polyps cannot be supported by the history and physical assessment.

· 2-Leiomyoma of uterus (D25)- Uterine fibroids are also known as leiomyomas. They are classified as benign growths, and they can either grow within the uterine wall or extend externally of the uterine surface (Hawkins et al., 2016; Schuiling & Likis, 2017). Typically fibroids will regress during menopause and are most common during the woman’s fertile years (Hawkins et al., 2016). Mrs. NR is 61 years old. The most common symptoms include irregular menses, dysmenorrhea, change in bowel or urine control, and pelvic pain (Schuiling & Likis, 2017). The patient did not report changes in bowel movements or problems with urination. Depending on the size and location of the fibroid, the practitioner maybe able to palpate a fibroid when examining the abdomen or performing a bimanual exam (Schuiling & Likis, 2017). Palpable masses or tenderness were not noted during the abdominal and pelvic exam. At this time, Leiomyoma of the uterus is not supported by clinical and physical assessment. Fibroids would need to be confirmed with a transvaginal ultrasound.

· 3- Malignant neoplasm of endometrium, part unspecified (C541)- Malignant neoplasm of the uterus can be considered the third differential diagnosis. The most common symptom is postmenopausal bleeding (Ferris, 2017). The risk factors for uterine neoplasm are obesity, diabetes, poly ovarian cystic disease, and atypical endometrial hyperplasia (Ferris, 2017). An endometrial biopsy or dilation and curettage will confirm the diagnosis of endometrial cancer (Ferris, 2017). Although the patient is obese, a diabetic, and her menarche occurred during the age 10, the student and preceptor cannot definitively diagnose the patient with endometrial cancer because they are not able to order and have the results of an endometrial biopsy due to insurance approval.

Diagnosis

· Postmenopausal bleeding (N950)- Postmenopausal is the final diagnosis. Postmenopausal bleeding is abnormal and could indicate a life-threatening condition. The structural abnormalities that are involved with abnormal bleeding are polyps, adenomyosis, leiomyoma, and hyperplasia or malignancy (Schuiling & Likis, 2017). The preceptor and student have strong suspicion that Mrs. NR has developed endometrial cancer or atypical hyperplasia. Women who are obese are at increased risk of developing endometrial cancer versus women who are within normal weight standards. Mrs. NR’s BMI is 58.2. Until the patient’s insurance company approves coverage for an endometrial biopsy, the preceptor and student cannot make a actuate diagnosis; therefore, postmenopausal bleeding is the final diagnosis during this visit.

Plan/Therapeutics

· Plan: 

· Further testing: Endometrial biopsy and pap smear test is ordered and waiting for an approval from Humana insurance company.

· Medication: None

· Education: The patient is educated on several different approaches that can be taken in managing her postmenopausal treatment plan. She is informed that the first step to managing her care is to perform an endometrial biopsy. The physician and student informed the patient that the biopsy can be performed at the clinic and the test can be accurate if an adequate amount of specimen can be obtained (Schuiling & Likis, 2017). They also discussed the possibility of receiving a more aggressive approach in diagnosing the cause for her vaginal bleeding. These approaches include a dilation and curettage or a hysteroscopy. Mrs. NR was informed that the greatest risk for both of these approaches includes increased risk for infection and perforation of the uterus. The physician did inform the patient that she is very suspicious of endometrial cancer. The student and her preceptor educated the patient about the differences between endometrial, ovarian, and cervical cancer. The physician informed Mrs. NR that endometrial cancer is usually diagnosed at stage 1, and prognosis is usually good (Morice, Leary, Creutzberg, Abu-Rustum, 2016). The physician also educated the patient on the fact if she does have an advanced stage of endometrial cancer she would display the signs and symptoms of ovarian cancer, which include abdominal pain or abdominal distention (Morice et al., 2016). Finally, Mrs. N.R. was educated on several different treatment plans can be performed if she is diagnosed with endometrial cancer. These treatment regimens include a total hysterectomy and possibly a pelvic lymph node dissection.

· Non-medication treatments: None

· Follow-up: The clinic will contact Mrs. N.R. by phone when they receive approval from insurance company to be scheduled for endometrial biopsy.

 Evaluation of patient encounter