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


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


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.



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. 

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. 


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

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