Discussion: Case Study: Common Gynecologic Conditions, Part 2

Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, diagnostic approaches, as well as to the development of treatment plans.

For this Case Study Discussion, you will propose a case study to your instructor that demonstrates a gynecological disease process from your practicum experience or your professional practice that would be quite challenging for you as a clinician. Once your instructor approves your case study, you will then explore this case study to determine the diagnosis, diagnostic tests, and treatment options for the patient.

To prepare:

• Consider a case study you would like to propose to your instructor related to a patient that demonstrates a gynecological disease process in your practicum experience or professional practice that would be your biggest challenge as a clinician. Note: Possibly use your “FNP or AGPCNP Skills and Procedures Self-Assessment” in your practicum experience to guide your case study selection.
• Review the Learning Resources for this week and specifically review the clinical guideline resources specific to your proposed case study.
• Use the Focused SOAP Note Template found in the Learning Resources to support Discussion.

By Day 1

Email your instructor with your proposed case study for approval. Once approved, you may move on to your Day 3 Discussion post.

By Day 3

Based on your approved case study, post the following:

• Describe your case study
• Provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
• Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.
• Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.
• Also, share with your colleagues your experiences as well as what you learned from these experiences.

Use your Learning Resources and/or evidence from the literature to support your thinking and perspectives.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests or treatment options your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position.

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Episodic/Focused SOAP Note Template

Patient Information:

Initials: S.K.

Age: 37 years old

Sex: Female

Race: Caucasian

Subjective

CC (chief complaint): right-sided abdominal pain

HPI:  the patient was a 37 year old Caucasian female who presented with complaints of right-sided abdominal pain for one week. She describes the pain as dull with an intensity of 6/10. She reports that the pain’s intensity increased today morning as she was working out when she felt a sudden sharp right-sided pain.

It is aggravated with physical activity and mildly relieved with a heat pad. The pain is non-radiating and is associated with abdominal bloating, loss of appetite ad increased urinary frequency. She denies past episodes of abdominal pain. She denies diarrhea, vomiting, nausea, and fevers. She informs that in the past two months, her   pant size had gone up.

Onset: sudden

Location: right-sided

Duration: one week ago

Characteristics: dull and sharp

Aggravating factors: aerobics

Relieving factors: heat pad

Timing: continuous

Severity: 6/10

Current Medications: multivitamin and ibuprofen when she has a headache

Allergies: No known drug, food or environmental allergies

PMHx: Up-to-date with all immunizations, she gets migraines

Soc & Substance Hx: S.K. is a 37 year old Caucasian female who works full-time as a tour guide. She is in a monogamous marriage. Her husband is an airline pilot. She consumes a glass of wine every evening with dinner. She denies illicit/recreational drug use and tobacco smoking.

Fam Hx: her mother was diagnosed with cervical cancer at 50 years. Her sister was diagnosed with   breast cancer at 38 years. Her maternal grandmother   had ovarian cancer. Her father and elder brother are however alive and healthy with no underlying chronic/familial illnesses.

Mental Hx: she denies past or current history of depression or anxiety, homicidal and suicidal ideation or self-harm practices.

OB/GYN History: LMP 06/24/2021, G0P0

Menstrual History:

1. Age of menarche: 10 years old
2. LMP: 06/24/2021
3. Menstrual Pattern: 28-30day cycle
4. Duration of flow: 4 – 5 days
5. Amount of flow: the last  menstrual period was  reportedly late and  very light(spotting)
6. Associated pain with menses: denies
7. Intermenstrual bleeding: denies
8. Menopause: not applicable

Contraception:

1. Current Method of Satisfaction: presently, the patient  informs that they use  safe-days
2. Previous method, complications and reasons for discontinuation: no history of past contraception use

Cervical and Vaginal cytology and Immunization:

1. History of abnormal pap smears: None
2. Date and Results of last pap smear-10 months  ago

Infections:

1. Reports no STI history

Sexual History:

1. Identifies as a heterosexual
2. She reports no current or past sexual assault.
3. Sexually active only with her husband

Review of Systems

General: the patient is a 37-year-old Caucasian female who appeared in office independently. She reports a history of travel from Paris one month ago. She reports an increase in abdominal girth. She denies fevers, fatigue, chills, fever, weight loss, and night sweats.

Respiratory: the patient denies DIB (difficulty breathing), wheezing, shortness of breath (SOB), and cough,

Gastrointestinal: the patient reports loss of appetite and right-sided abdominal pain. She denies vomiting, nausea, diarrhea, abdominal trauma, and changes in bowel movements.

Genitourinary: the patient reports increased urinary frequency, denies dysuria, hematuria, hesitancy, or burning on urination.

Objective

Physical exam:

General: the patient is AOx4, NAD

VS: 97.8 °F, BP- 125/69 HR-68 (apical), RR-17, O2 sat-99% RA, Height- 5’8”

General Appearance: S.K. is AOx4. She appears to be generally healthy; she is appropriately dressed for the weather and is well kempt. Her vital signs are within normal limits.

HEENT: Eyes: No exudate, crusting, or redness, lesions of eyelashes or eyelids. No conjunctival pallor, PERRLA, no enophthalmos, or exophthalmos.

Respiratory: resonant on percussion, lungs are bilaterally clear, rhythmic breathing, no use of accessory muscles to breathe, no wheezing, crackles, rhonchi, or rales.

Cardiovascular: S1 and S2 heard, no rubs, murmurs, or gallops. No pedal or facial edema.

Abdominal/GIT: No abdominal scars on inspection, abdomen moves symmetrically with respiration, bowel sounds are active and present in all abdominal quadrants, tympanitic on percussion, tender in the right lower quadrant on palpation.

Genital/Rectal:

1. External Genitalia

Vulva/Labia Majora: moist and intact skin, no erythema

Bartholin Gland: soft, no enlargement area pink and moist

Skene’s: moist and pink

Clitoris: pink with intact

2. Urethra: moist and pink, no abnormal discharge on contracting and releasing the muscles of the pelvis.
3. Bladder: non-distended and non-tender on palpation
4. Vagina: Normal pattern for hair growth, thin clear discharge, no odor
5. Cervix: friable, there is some petechiae with no cervical motion tenderness.
6. Adnexa: no palpable masses, or tenderness present with speculum manipulation
7. Rectum: the anus is pink and moist; good tone sphincter, with no fissures

Diagnostic results:

• CBC- to evaluate the patient for a possible underlying anemia of chronic disease (cancer)
• Transabdominal/Transvaginal Ultrasound (U/S)-to assess/evaluate the patient for the likelihood of a ruptured ovarian cyst and other ovarian pathologies
• Laparoscopy: to get a sample for histology since there is a high index of suspicion of ovarian cancer
• Serum β-HcG- to detect the likelihood of pregnancy since it is highly sensitive when compared to urine the β-HcG.

Assessment

1. Ovarian Cancer-ovarian cancer is among the most diagnosed gynecologic cancers in the US. Although it affects women of all ages, it is mostly diagnosed after menopause. According to the American Academy of Family Physicians (AAFP), the strongest risk factors accounting   for most ovarian cancers are family genetic syndromes (Doubeni, Doubeni & Myers (2016). However, additional risk factors include a family history of ovarian cancer/other cancers, nulliparity, early menarche, and weight gain/obesity. Patients who present early often have non-specific symptoms and may present with abdominal bloating, an increase in the abdominal size, and difficulties eating. The physical exam findings may be significant for pleural effusion, a pelvic/ovarian mass and ascites (Doubeni, Doubeni & Myers (2016). Patient S.K. presented with complaints of increased urinary frequency, d ll lower abdominal pain, changes in her menstrual cycle (spotting), and a decreased appetite. Her history was significant breast cancer, cervical cancer, nulliparity, and early menarche. The physical exam was significant for a 37 year old obese Caucasian female with an increased abdominal girth increase the likelihood of an ovarian cancer diagnosis. A confirmatory test with BRCA genetic testing would be the most appropriate.
2. Ectopic Pregnancy- in ectopic pregnancy, a fertilized ovum gets implanted in another location other than the uterine cavity. The most common location is the fallopian tube. Patients will report a history of possible amenorrhea, increased urinary frequency and abdominal girth, and nausea (Hendriks, Rosenberg & Prine, 2020). They will also report of a unilateral colicky abdominal pain that becomes generalized over time. The fact that S.K. uses the calendar contraception method further increases the likelihood of this diagnosis by suggesting a possible pregnancy. S.K’s history of a dull then sharp pain of sudden onset and tenderness on the right lower quadrant on palpation suggest this diagnosis. However, the fact that the patient described this pain as dull, and sharp with a sudden onset and denied associated symptoms of diarrhea, vomiting, or syncope decreases the likelihood of this diagnosis.
3. Ruptured Ovarian Cyst-according to Zahidy & Abdulkareem (2018), patients with a ruptured ovarian cyst may exhibit irregular menstrual cycles, and frequent micturition due to the pressure applied on the bladder. While S.K. had these symptoms, she also reported a sharp lower abdominal pain of sudden onset that began during exercise. The nature of this pain is characteristic to that of a ruptured ovarian cyst and mostly occurs among women of reproductive age aged 8-35 years. However, the suggestion of this diagnosis does not comprehensively account for her history of a one week dull abdominal pain and abdominal bloating.

Plan

• Immediate referral to an oncologist for further evaluation and management (laparoscopy, histology, staging, and surgery).

References

Doubeni, C. A., Doubeni, A. R., & Myers, A. E. (2016). Diagnosis and management of ovarian cancer. American family physician, 93(11), 937-944.

Hendriks, E., Rosenberg, R., & Prine, L. (2020). Ectopic pregnancy: diagnosis and management. American family physician, 101(10), 599-606.

Zahidy, A., & Abdulkareem, Z. (2018). Causes and management of ovarian cysts. The Egyptian Journal of Hospital Medicine, 70(10), 1818-1822.