diagnosis 17 & 24

Mrs. Parker is a 55-year-old Caucasian female with two weeks of intermittent vaginal bleeding. She has received hormone replacement therapy since menopause (HRT). She is obese and has a history of hypertension and hypothyroidism for which she takes Lisinopril and Synthroid.

55-year-old female, G2P2

Menarche age 11

Hypertension

Intermittent vaginal bleeding for the past two weeks

Obesity 36kg/m2

Family history of osteoporosis, HTN, DM (mother)

Postmenopausal

Father history of Heart failure

Bleeding was sufficient to wear a pad

Several maternal aunts HTN, DM

Bright red x 4 days, then brown discharge (like a normal period)

Paternal grandfather heart attack

Bloating

PMH: hypothyroidism treated with levothyroxine medication.

Estrogen hormone replacement

The thyroid is normal in size and no nodules.

Hot flashes

No abdominal cramping

No abnormal pap smears

The thyroid is normal in size and no nodules.

The vaginal dome appears shiny and free of malignancy, but the vaginal wall is still folded inward, resulting in a reduced number of rugae. Similar to the ovaries, the cervix is silky and bloody with no abnormalities

There are no sores on the labia and minimal pubic hair on the external genitalia

Small blood vessels and an os can be removed with wipes from the surface of the cervix, which is smooth. On the cervix, there are no tumors.

There is a small bit of red blood at the cervix, but it is easily removed.

Her ovaries were inaccessible due to her being overweight, but her cervix was free to move and not sensitive.

Mrs. Parker, a 55-year-old menopause cisgender female, has experienced intermittent vaginal bleeding for the previous two weeks. The bleeding is comparable to a typical period, consisting of four days of bright red blood followed by brown discharge, and it is severe enough that a pad must be used. She has stomach distention but denies having abdominal cramps. Menarche began at the age of 11, past pap smears have all been normal, and she has no family history of malignancy.

Light vaginal bleeding for two weeks with no associated cramps.

Thin pubic hair. Red blood not at the cervix, easily wiped away. Vaginal vault has decreased rugae with a shiny appearance. Cervix is smooth with a small os with a small amount of blood with no lesions. Cervix is freely movable and non-tender.

Menarche at 11, LMP: 3 years ago, G2P2

PE: Abdomen: Her bowel sounds are normal and there is no hepatomegaly or other masses appreciated. Although her abdomen is obese, she is not distended. There is also no abdominal tenderness

Med list: Levothyroxine 100 mcg daily, Lisinopril 20 mg daily, Estrogen/medroxyprogesterone 0.625/2.5 mg daily

PE: HEENT: Pupils are equal, round, and reactive to light. Thyroid: No nodules and a normal size thyroid.

Pap smear 4 years ago and result was normal

Vital signs: BP 132/80 mmHg, PR 88, Weight 95.3 kg, Height 163 cm BMI=36.

No family history of cancers

Normal. HPV high-risk testing negative

PMH: Menopause, hypertension, hypothyroidism, and obesity.

Ultrasound: The uterus is normal size, endometrial stripe is 6mm, with no lesions. Ovaries are normal size and morphology for age.

TSH: 1.0 U/mL

Hgb: 13.4g/dL, Plts: 350,000/uL

Endometrial Biopsy: Confirms proliferative endometrium

Light vaginal bleeding for two weeks with no associated cramps.

Thin pubic hair. Red blood not at the cervix, easily wiped away. Vaginal vault has decreased rugae with a shiny appearance. Cervix is smooth with a small os with a small amount of blood with no lesions. Cervix is freely movable and non-tender.

Menarche at 11, LMP: 3 years ago, G2P2

PE: Abdomen: Her bowel sounds are normal and there is no hepatomegaly or other masses appreciated. Although her abdomen is obese, she is not distended. There is also no abdominal tenderness

Med list: Levothyroxine 100 mcg daily, Lisinopril 20 mg daily, Estrogen/medroxyprogesterone 0.625/2.5 mg daily

PE: HEENT: Pupils are equal, round, and reactive to light. Thyroid: No nodules and a normal size thyroid.

Pap smear 4 years ago and result was normal

Vital signs: BP 132/80 mmHg, PR 88, Weight 95.3 kg, Height 163 cm BMI=36.

No family history of cancers

Normal. HPV high-risk testing negative

PMH: Menopause, hypertension, hypothyroidism, and obesity.

Ultrasound: The uterus is normal size, endometrial stripe is 6mm, with no lesions. Ovaries are normal size and morphology for age.

TSH: 1.0 U/mL

Light vaginal bleeding for two weeks with no associated cramps.

Thin pubic hair. Red blood not at the cervix, easily wiped away. Vaginal vault has decreased rugae with a shiny appearance. Cervix is smooth with a small os with a small amount of blood with no lesions. Cervix is freely movable and non-tender.

Menarche at 11, LMP: 3 years ago, G2P2

PE: Abdomen: Her bowel sounds are normal and there is no hepatomegaly or other masses appreciated. Although her abdomen is obese, she is not distended. There is also no abdominal tenderness

Med list: Levothyroxine 100 mcg daily, Lisinopril 20 mg daily, Estrogen/medroxyprogesterone 0.625/2.5 mg daily

PE: HEENT: Pupils are equal, round, and reactive to light. Thyroid: No nodules and a normal size thyroid.

Pap smear 4 years ago and result was normal

Vital signs: BP 132/80 mmHg, PR 88, Weight 95.3 kg, Height 163 cm BMI=36.

No family history of cancers

Normal. HPV high-risk testing negative

PMH: Menopause, hypertension, hypothyroidism, and obesity.

Ultrasound: The uterus is normal size, endometrial stripe is 6mm, with no lesions. Ovaries are normal size and morphology for age.

TSH: 1.0 U/mL

Hgb: 13.4g/dL, Plts: 350,000/uL

Pap smear with HPV

In conjunction with human papillomavirus (HPV), cervical cytology is used for cervical cancer screening. It can detect both low-grade and high-grade squamous intraepithelial lesions (LSIL and HSIL, respectively) (HSIL). She is due for a repeat pap smear and cytologic assessment to rule out cervical cancer (Cash & Glass, 2020).

Complete Blood Count (CBC)

To rule out anemia and thrombocytopenia

Thyroid Stimulating Hormone (TSH)

To determine TSH level .Thyroid disorders may result in abnormal bleeding. (Cash & Glass, 2020).

Mammogram

To screen for breast cancer. Recommended every 1 to 2 years for women over 50 at average risk for breast cancer (Qaseem et al., 2019).

Transvaginal Ultrasound (TVUS)

Initial test that is economical for evaluating the thickness of the endometrium. Transvaginal ultrasonography (TVUS) endometrial thickness measurement is a noninvasive approach for evaluating individuals with postmenopausal bleeding for endometrial hyperplasia or malignancy (Singh & Puckett, 2020).

Endometrial biopsy

Highly recommended for women with uncontrolled menstrual bleeding (Singh & Puckett, 2020).

Discontinue HRT

Estrogen treatment increases endometrial thickness (Singh & Puckett, 2020).

Calcium 1,200 mg take 1 tablet PO daily

Necessary for the development and maintenance of strong bones (Rosen et al., 2022).

Vitamin D 800-1000 IU daily.

Necessary for the development and maintenance of strong bones (Rosen et al., 2022).

Create a weight bearing exercise plan that is right for the patient.

Strengthening muscles and bones, and preventing additional bone loss, is the primary function of exercise (Cash & Glass, 2020).

Encourage the patient to eat a regular well-balanced diet.

Increasing dietary protein, vitamin D, and calcium helps strengthen bones (Cash & Glass, 2020).

Follow up in 3 months or sooner if vaginal bleeding continues