N675L Week 7 – GYN and STI Assignment with complete solution

Week 7 – GYN and STI In Canvas - Instructions – You are a NP in a PRIMARY CARE PRACTICE. Please succinctly note in the following five (5) cases your responses. You are only asked to address actions or items for this INITIAL PRIMARY CARE VISIT. Case 1 You are a NP in a primary care clinic. You are seeing a pt with a CC of “bleeding in between period.” She is a 48 G3P3 year-old woman who presents with intermenstrual bleeding x2 mos. She is c/o BRB, but lighter than her normal period. She reports it can last 1-6 days. She denies pain, hot flushes, or night sweats. She is monogamous, and is sexually active with her long-term male partner. She denies any vaginal dryness and with no associated pain. Q1: How would you further investigate and manage this pt? I would address the following things: Thorough history and physical using the PALM (polyps, adenomyosis, leiomyomata, malignancy) and COEIN (coagulation disorders, ovulatory dysfunction, endometrial, iatrogenic, not yet classified) screening tools, past medical history, last PAP smear, and current medications taken. Physical exam to include a pelvic exam, breast exam, thyroid exam, pulmonary and cardiovascular. Q2: What are your ddx? Please select the three (3) MOST PROBABLE ddx, and your rationale for selecting it as your dx or your r/o. The differential ddx: 1) Uterine/endometrial Cancer bleeding pattern regular but heavy and prolonged, enlarged uterus on examination, discrete masses may be palpated. The patient states that she is having intermenstrual bleeding 2) Irregular bleeding due to OCP (oral contraceptive pills) irregular or heavy bleeding related to OCPs or IUDs. The H&P would rule out the use of either modalities. The patient is not on OCPs or IUDs 3) Endometrial polyps (leiomyomas) regular menses with intermenstrual bleeding. Endometrial polyps are more likely to be malignant in postmenopausal women who present with bleeding. The polyps should be removed to assess for malignancy and to stop the bleeding. Final DX: Endometrial polyps because they are a common cause of abnormal uterine bleeding in both pre and post-menopausal women. Case 2 1 This study source was downloaded by from CourseH on :06:04 GMT -05:00 You have a new pt that is establishing care. She is 21 y/o nulliparous and not sexually active. She asked you whether there is a need for her to have a “woman’s exam.” Q1: How will you respond to her statement? Your response will be: I would provide a print out of the latest guidelines and educate the patient about the current recommendations. The current USPSTF guidelines recommend cervical cancer screening for women 21 to 65 years of age with cytology PAP smear every 3 years. Women 30-65 need a PAP smear and HPV testing every 5 years. On visit #2, this same pt, RTC for review of her lab and pap result. Her pap result is as follows: Aypical squamous cells of undetermined significance (ASCUS) - Low-grade squamous intraepithelial lesion (LSIL), hrHPV negative Q2: What is your interpretation of this result, and what will you tell your pt (next step)? Atypical squamous cells of undetermined significance (ASCUS) are thin and flat they grow on the surface of a healthy cervix. On the Pap smear, ASCUS are slightly abnormal squamous cells, but the changes do not clearly suggest precancerous cells are present. ASCUS indicates some abnormality, but the cause is not clear. If the cytology is unsatisfactory then repeat testing in 1 year (30 yrs old) or continue routine screening (21-29 yrs old) then resume routine screening if testing is normal at 3 years. If the cytology is positive for intraepithelial lesion or malignancy (+ or – HPV) referral for colposcopy required. Low-grade squamous intraepithelial lesion (LSIL) indicates mild dysplasia or cervical intraepithelial neoplasia (CIN) I negative for HPV high risk. Next step: Pt is 21 years old she would need to repeat PAP with HPV testing in 12 months. If results are unsatisfactory then refer for colposcopy if results are normal test at 3 years then routine screening. Case 3 28 y/o woman RTC for abnormal Pap smear result. She is very anxious as she thinks that she might have cervical cancer. The Pap smear result is reported as “LSIL, hrHPV positive or unknown.” She had a previous normal result at age 25 yrs. She has not had any postcoital or intermenstrual bleeding or dysparenuia. Q1: Any other information you would like to know? -Do you have any chronic conditions? -Have you ever had a STI? -What medications are you taking? -Do you use birth control, if so which kind of birth control? -How many sexual partners do you have? -What age did you start having sexual intercourse? -Do you smoke or use any recreational drugs? 2 This study source was downloaded by from CourseH on :06:04 GMT -05:00 Q2: Will your additional information change your management? No, the guidelines will remain the same regardless of the HPI. Q3: How should this pt be managed (next step)? The pt has LSIL, (+) hrHPV or unknown normal result previously she needs to get a Colposcopy Case 4 A 36 year-old anxious woman self presented to clinic due to her vaginal d/c for the last 10 days. c/o annoying d/c that saturates through her dayliner. “It smells, and it’s embarrassing.” Reports white d/c with some itching and occasional burning on urination. She denies dyspareunia. Reports had STI in her teens but cannot recall exactly what it was, but she was treated. Reports 2 male partners the past 6 mos. Reports 100% condom use. Q1: You obtained all the additional information that you needed, what will do for your PE? Focused exam to include general, pulmonary, CV, GI and pelvic exam Whiff test, Wet mount, pH test, Pregnancy test, Urinalysis, STI tests (gonorrhea, chlamydia), syphilis tests (rapid plasma regain or venereal disease research laboratory) Labs Hepatitis panel Case 5 A 46 year-old woman c/o heavy vaginal bleeding. Her menstrual cycle has not changed, but over the past year, she has noticed increasingly heavy periods, with blood clots, needing more pad changes than usual. c/o fatigue the past 3 mos, prompting her visit today. Q1: What will you do next? Obtain HPI to include OLDCARTS (PALM & COEIN screening tools) PE to include pulmonary, CV, GI and Pelvic exams UA Pregnancy test Check HGB in the office then labsCBC, CMP, TSH, PT/INR and PTT Q2: What is the most likely dx? Normal menstrual cycles but heavy menstrual period with blood clots over past year, requires more pad changes that usual fatigue over 3 months Leiomyomas (Fibroids)  abnormal uterine bleeding and menstrual cramps that cause heavy menstrual cycles dx via pelvic exam and U/S I believe the pt has fibroids because of heavy cycles. Endometrial Polyp  regular menses with intermenstrual bleeding. Endometrial polyps are more likely to be malignant in postmenopausal women who present with bleeding. The polyps should be removed to assess for malignancy and to stop the bleeding. Endometrial Cancerenlarged uterus, painless menorrhagia weight loss and weakness. It can cause heavy bleeding a pelvic U/S should be done to rule out cancer along with a biopsy