Walden University Case Study: Postmenopausal Bleeding

Case Study 1 Case Study: Postmenopausal Bleeding

Thelma Smith is a 58-year-old African American female who presents to the office with the complaint of brown discharge for several days last week. Her medical history is remarkable for type 2 diabetes somewhat controlled with glipizide and metformin (last A1C 7.5). She is a G0, having never been able to get pregnant. She is up to date with mammograms and has had a colonoscopy 1 year ago, all normal. Her pap history is normal with her last pap 2 years ago reported an NILM HPV negative, atrophic changes, no endocervical cells noted. Vital signs temperature 98.1 BP 140/88, pulse 82, respirations 12. She is 5’6” and 272 lbs. (BMI 43.90). Focused exam:

• Abdomen: soft, obese, +BS

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• VVBSU: brown dischargenoted,

• Cervix: brown blood noted coming from os, no cervical motiontenderness

• Uterus: unable to assess due to bodyhabitus

• Adnexa: unable to assess due to body habitus Case Study 2 Case Study: Dysfunctional Uterine Bleeding Gretchen Abernathy is a 38-year-old G2 P2 Caucasian female who presents to the clinic with complaints of frequent menstrual bleeding. Her menstrual calendar shows bleeding frequency 17-36 days, lasting 5-10 days in duration and on her heaviest day she needs to change her super tampon every 2 hours. She relates this has been getting worse since stopping her OCP’s when she had a bilateral tubal ligation 4 months after having her second child 9 months ago. She is upset as no one told her that weight gain could happen after and relates she has gained 27 lbs. since her surgery. She states that all this bleeding is making her tired and she cannot keep herself awake. Gretchen’s mother told her she probably just had “low iron” and if she took vitamins, she would feel better. • HEENT: wnl, hair dry, neck supple withoutadenopathy • CV: RSR without murmur orgallop • Lungs: clear top&a. • Abd soft, non-tender, BS all 4quadrant. • VVBSU:WNL • Cervix: firm, smooth, parous, w/oCMT • Uterus: mid mobile non tender, approximately 10cm • Adnexa: without masses or tenderness • Extremities: negative homan’s, reflexes 2+ = bilaterally, noedema Case Study 3 Case Study: Urinary Leakage Mable Albright is a 48-year-old, native American who presents to your clinic with the complaint of urinary leakage. She relates this has been worsening over the past 2 years. She now must wear a pad all the time and states it is interfering with her work as she is going to the bathroom all the time. Medical history is negative, surgical history is remarkable for wisdom teeth and a bilateral tubal ligation. VSS: and normal 5’0 172 lbs. (BMI33.6) Case Study 4 Case Study: Obstetrics Scenario 1 Phillipa Hudson is a 29-year-old female presenting today at your clinic with a positive home pregnancy test. Her medical history is negative. Surgical history negative. Gyn history 1st menses age 12, with cycles coming every 28 days and lasting for 5 days. Her pap and std history are negative. She has been taking a woman’s gummy vitamin for the past year. Her OB history is as follows: Date gestation outcome gender wt. anesthesi a complication s 1-2011 6 TAB None 4-2014 39 Low forceps delivery male 8’14” epidural Gestational diabetes 5-2016 8 weeks SAB 8-2016 35 weeks NSVD female 6’6” local None 7-2017 38 weeks SVD male 8’10” local Gestational diabetes Phillipa relates her last period (LMP) was 12-10-2021. She reports breast tenderness, fatigue, and nausea (which is what made her suspect she was pregnant). • Smoking/Alcohol/recreationaldruguse.Anypotentialchemicalexposuresathomeor work. Social history such as relationship status, living situation, support system, job type, dietaryrestrictions. Update: Height, weight, vital signs Phillipa denies smoking, alcohol, and recreational drug use. She is a warehouse supervisor at Amazon and works 36 hrs. per week. She and her fiancé have been together for 5 years, and he works in an accounting office. They live in a 3-bedroom townhouse within easy walking distance to schools and stores. Her fiancé’s parents live in the same complex they do, and her parents and younger sister live about a mile away. Phillipa relates she is become a vegetarian since her last pregnancy. Her vital signs at her first visit height 5’4” weight 176 lbs. and her BP is 112/68 Case Study 5 Case Study: Obstetrics Scenario 2 Phillipa Hudson is a 29-year-old female presenting today at your clinic with a positive home pregnancy test. Her medical history is negative. Surgical history negative. Gyn history 1st menses age 12, with cycles coming every 28 days and lasting for 5 days. Her pap and std history are negative. She has been taking a woman’s gummy vitamin for the past year. Her OB history is Date gestation outcome gender wt. anesthesi a complication s 1-2011 6 TAB None 4-2014 39 Low forceps delivery male 8’14” epidural Gestational diabetes 5-2016 8 weeks SAB 8-2016 35 weeks twins NSVD Female Female 6’6” 7’1” epidural Di/di twins 7-2017 38 weeks SVD male 8’10” local Gestational diabetes Phillipa relates her last period (LMP) was 12-10-2021. She reports breast tenderness, fatigue, and nausea (which is what made her suspect she was pregnant). Case Study 6 Case Study: Obstetrics Scenario 3 Phillipa Hudson is a 39-year-old female presenting today at your clinic with a positive home pregnancy test. Her medical history is negative. Surgical history is remarkable for a c section. Gyn history 1st menses age 12, with cycles coming every 28 days and lasting for 5 days. Her pap and std history are negative. She has been taking a woman’s vitamin for the past 6 years. Her OB history is: Date gestatio n outcome anesthesi a Length of labor weight gender complication s 1- 2015 41 weeks nsvd epidural 18 7’6 female none 2- 2016 37 weeks nsvd epidural 6 7’11” female Disappearing twin 3- 2017 39 weeks Primary c/s spinal na 8’2” male c/s for breech after failed version 3- 6 weeks ectopic Treated with 2019 methotrexate Phillipa relates her last period (LMP) was 12-10-2021. She reports breast tenderness, fatigue, and nausea (which is what made her suspect she was pregnant).

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