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
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
