Clinical Objective
Clinical Objective: To document in sufficient detail a patient encounter and demonstrate the application of clinical skills in advanced assessment of a bleeding disorder in an adult female with a co-morbid chronic disease. Additionally, to demonstrate the integration of pharmacological and non-pharmacological treatments for a common health complaint
Subjective Information
Date: 2022-10-17
Time:
Patient Initials: PH
Patient Age: 78
Gender: Female
Marital Status: Married
Ethnicity/Country of Origin/Race: African American
Religion: Christian
Occupation: Retired Administrator
Language: English
Military Status: None
Chief Complaint (CC): I am so tired and finding it difficult to breathe. I have been also been bleeding.
History of Present Illness (HPI): PH is a 78-year-old, slightly overweight White woman who complains of easy fatigability, shortness of breath, and vaginal bleeding. She has been on management for asthma which was under control until recently.
General/Constitutional: Well developed, well nourished, slightly overweight. Briefly stops mid-sentence to take deep breaths.
Review of System (ROS)
Skin: Denies hair, skin, and nail changes. No moles, rashes, lumps, and itching
HEENT: Head: reports minor headaches relieved by rest and sometimes Tylenol. Denies hair loss. Eyes: denies vision changes, pain, or itching. Ears: denies ringing, discharge, hearing loss, vertigo, or pain. Nose: denies congestion, rhinorrhea, or bleeding. Mouth/Throat: no dental or throat pain.
Neck: Normal range of motion, denies changes in pigmentation and skin thickness
Breast: Denies bumps, lumps, nipple discharge
Chest/Respiratory/Cardiac: Reports shortness of breath. Reports raising the head of the bed to sleep comfortably. Denies wheezing, chest pain, and cough.
Gastrointestinal: Denies abdominal pain, dysphagia, nausea, vomiting, diarrhea, constipation
Urinary: Denies urinary urgency, frequency, hesitancy, polyuria, nocturia, incontinence, hematuria, dysuria, kidney stones, and urinary tract infection
Genitalia: Reports vaginal bleeding. Denies discharge, itching, and pain.
Peripheral Vascular: Denies bruising, sores, slow healing wounds, gangrene, petechiae
Hematologic: Denies blood transfusions, pallor, bruising, anemia, adenopathy, chills, and sweats. Reports vaginal bleeding.
Endocrine: Denies increased thirst, hunger, gain or loss of hair, heat or cold intolerance, night sweats, and recent weight loss or gain.
Musculoskeletal: Reports fatigue. Denies muscle cramps, joint stiffness, and weakness.
Neurologic: Denies changes in sleep, concentration, balance, abnormal thoughts, seizures, paralysis, blackouts., weakness, and paresthesia.
Mental Status: Reports anxiety. Denies depression, paranoia, suicidal ideation, memory changes
Lymph: Denies adenopathy, fever, and chills.
Medications: Tylenol 500mg 2 tablets PO q6h X pain Advair Diskus 250/50 one puff q12h Ventolin HFA 100mcg 1-2 puffs q6h X DIB/Wheezing
Allergies: No known allergies
Past Medical History: No other health complaints
Past Surgical History: No surgical history
Immunizations: Annual Flu vaccines, Tdap, and Pneumo-23 as per CDC guidelines. Two doses of Moderna COVID-19 mRNA. Received recommended pediatric vaccine
Screening Tests (for Health Maintenance): DEXA as per CDC Last Pap smear at 70, normal Last mammogram at 77, normal Last cholesterol screen at 75, normal Colonoscopy at 75, normal
Family History: Both parents deceased. Father died in an auto-accident at 65, mother due to natural/old age causes at 88. Younger sister (74) on treatment for diabetes and hypertension, brother (72) on treatment for rheumatoid arthritis.
Social History: Separated mother of three. PH works as a hairdresser in her salon two blocks from home. She walks to and from work. Denies smoking, drinking, and illicit drug use. She reports she does not get 150 hours of physical exercise weekly.
Blood Pressure: 142/93 (Left arm, sitting).
Objective Information
Vital Signs
Temperature: 98.4 degress, oral.
Pulse: 82 per min.
Pulse Oximeter: 95% on room air.
Respirations: 22 per minute.
Pain Score: N/A
Weight: 155 lbs.
Height: 5’9″
BMI: 25.7
Last Menstrual Period (LMP): N/A
General: General appearance: Female white American. Slightly overweight, well-nourished, pale, tired-looking, and mildly anxious. HEENT: Head normocephalic, hair thinning, and no masses, scars, or depressions noted. Reports minor headaches treated with rest and OTC Tylenol. Facial and neck movements were normal. Eyes: PERRLA present, EOM normal, conjunctiva pale, eyes sunken. Tympanic membranes clear and color normal, cerumen consistency and quantity normal. Mucosal membranes pale. Tonsils, pharynx normal color, no inflammation of cervical and neck lymph nodes Chest: chest wall symmetrical, respiration fast and regular, wheezing and lung sounds heard Heart: S1, S2 heard. No murmurs, rubs, or gallops. Regular HR and rhythm. Gastrointestinal: Abdomen round and soft. Bowel sounds are audible in all quadrants. Skin: Pale, itchy, and dry. Skin temperature was normal, hair thin and evenly distributed, skin turgor decreased, and capillary refill slightly increased to four seconds. Hematological: Pallor noted on mucus membranes, palms, nail bends, and conjunctiva. Genitourinary: No urinary catheter, suprapubic tenderness, inflammation, discharge, and lesions noted. Cervix eroded, bleeding, no cervical mass.
Individual Systems
Lab Test/X-ray Results: Pap Smear HPV test Complete Blood Count Chest X-ray
Procedures: Pelvic examination
Assessment
Differential Diagnoses: 1. Cervical cancer 2. Anemia 3. Asthma
Assessment: Cervical cancer is the third most common malignancy in women worldwide, accounting for many cancer deaths in developing countries. In the West, HPV vaccination and improved screening have lowered cervical cancer incidence. Early symptoms include vaginal bleeding, malodorous discharge, dysuria, and vaginal discomfort. Diagnosis relies on abnormal histological findings in tissues extracted through a Pap test. Confirmatory testing consists of finding human papillomavirus infection in the cervical tissue. HPV infection is necessary to develop the malignancy; however, less than 5% of persons with the infection develop carcinoma in situ (CIN), the precursor cellular transformation for the disease (Liu et al., 2017). Consequently, sexual behaviors, such as the early onset of sexual activity, multiple sexual partners, promiscuous male partners, and sexually transmitted diseases, increase the risk (Mekuria et al., 2021). Additionally, increasing age and use of oral contraceptives are other risk factors. A pelvic exam helps diagnose cervical erosions, color changes, and bleeding in complaints of vaginal bleeding. However, diagnosis may be delayed due to misdiagnosing vaginal bleeding as menstrual and post-menopausal abnormalities. Prolonged vaginal bleeding may lead to anemia.
Plan
Plan
1. Pharmacologic: 1. The facility adopted the restrictive recommendation for transfusion; hence the patient with HGB qualified for transfusion with one pint of packed red blood cells. 2. Tranexamic acid 500mg PO TDS for 3-5 days
2. Non-Pharmacologic: These include a diet rich in iron (eggs, meat, fish, peas, beans) and anti-oxidants. Physical exercise and avoiding triggers, such as dust, cigarette smoke, and anxiety
3. Diagnostics: Pap smear HPV
4. Patient Education: The patient will be educated on the following: 1. Maintaining a healthy weight. 2. Avoiding asthma attacks triggers 3. Referral to an oncologist
5. Referrals: 1. Oncologist 2. Hematologist
6. Health Maintenance/Follow-up: 1. Adherence to medication, and physical activity. 2. Test results for Pap smear and HPV
References: Liu, M., Yan, X., Zhang, M., Li, X., Li, S., & Jing, M. (2017). Influence of human papillomavirus infection on the natural history of cervical intraepithelial neoplasia 1: A meta-analysis. BioMed Research International, 2017, 1–9. https://doi.org/10.1155/2017/8971059
Mekuria, M., Edosa, K., Endashaw, M., Bala, E. T., Chaka, E. E., Deriba, B. S., & Tesfa, B. (2021). Prevalence of cervical cancer and associated factors among women attended cervical cancer screening center at Gahandi Memorial Hospital, Ethiopia. Cancer Informatics, 20, 117693512110684. https://doi.org/10.1177/11769351211068431
ICD-10
1. ICD-10: C53.9
1. Diagnosis: Malignant neoplasm of cervix uteri, unspecified
2. ICD-10: D64.9
2. Diagnosis: Anemia, unspecified
3. ICD-10: J45.909
3. Diagnosis: Unspecified asthma
4. ICD-10: N/A
4. Diagnosis: N/A
5. ICD-10: N/A
5. Diagnosis: N/A
