CLASS

CERVICAL CANCER

Name

Institution

SUBJECTIVE DATA

Patient Initials: CR Age: 28 Gender: FEMALE

Chief Complaint (CC): “vaginal itching with irritation for 5 days.

History of Present Illness (HPI): CR is 28-years old. A Caucasian. She reported to the clinic complaining of a series of symptoms. These included painful coitus, dense vaginal exoneration and severe pelvic pain. The discharge was pinkish and bloody with odor. She explains that all the symptom’s intensity grew steadily within the last month. She however admits that she ignored the signs and thought they were just normal until the discharge, the odor, and the intercourse pain became too much to bear. She articulated that the discharge was somehow watery. Also, her periods became irregular and with heavy and prolonged menstrual flow. She however refuted occurrence of weight loss, fatigue and bone pain.

Onset: the patient has alleged that the conditions has been increasing steadily over the past one month.

Location: the pelvis

Duration: she claimed that she has started experiencing an odorful and pink discharge from her vagina for one week.

Characteristics: patient complained of vaginal pain after sex in multiple occasions, heavy menstrual flow, and a thick discharge of pink fluid with a sharp odor.

Aggravating factors: painful intercourse, as explicated by the patient.

Relieving factors: In her explanation, she didn’t experience any relieving factors.

Treatments/Therapies: The patient assumed the symptoms as normal hence did not seek any prior medication. This was her first pursue of medical attention.

Severity: the discharge, the odor, the painful sex and the heavy menstrual flow during and between the periods was too much for the patient to assume.

Medications: the patient undergoes chemotherapy and radiation therapy as her condition was clearly worsening and there was need to kill the growing cancerous cells in and around the pelvis.

Allergies: patient did not show any hypersensitive reactions to foods, medications and to the radiotherapy procedure.

PATIENT HISTORY

Past Medical History (PMH): She had a history of intensive contraceptive use. She was using a lot of p2 over the past six months

Past Surgical History (PSH): She has not been to any kind of surgery before.

OB/GYN History: CR acknowledged that she’s been using contraceptives intensively over the past six months. Her menses before last month had been regular. Her menstruation wasn’t heavy and lasted for exactly 4 days. In addition to that she said she has one partner and before the symptoms intensifying they had a hyperactive sex life.

Menstrual History: patient menses lasted for 28 days. It commences on the first day of the last period and halts on the first day of the next menstrual period.

Age at menarche – she had the first menstrual cycle at the age of 15years when her body reached maturity and was able to ovulate and produce ova.

LMP- the last menstrual period was reported on 1/ 11/2020

Menstrual Pattern: the patient had regular menstrual cycles

Duration of flow- the flow was just 4 days

Amount of flow- the patient, had a heavy flow which was triggered by the cancerous cells.

Associated pain with menses- the patient experienced a lot of pain during the menses period.

Intermenstrual bleeding- the patient acknowledged intermenstrual bleeding in the past menstrual period.

Contraception: She acknowledged heavy usage of contraception especially within the last six months as they had a hyperactive sex life but didn’t wish to have any child in the process.

Cervical and vaginal cytology:

She has undergone two Pap smear at the age of 23 and 27 years . Pap smear test is done under high restrictions as its health effects are severe in case of regular conduction. She tested negative in the first test and positive in the second test.

History of abnormal pap smears- she has recorded one abnormal tests of pap smears at 27.However, her doctors recommended some therapy and in a few months she was declared normal again.

Infections: The patient says she has a monogamous but hyperactive sex life. Possibility of contracting any STI was therefore negligible.

FERTILITY/INFERTILITY:

Sexual History: She has one sexual partner and hasn’t seen abnormalities with the libido and orgasm. The stated symptoms didn’t allow her to have any sexual relations for the past 2 weeks. She denies any form of sexual abuse or assault. She hasn’t been sexually harassed.

Obstetric history: gravida2, para 2, arbortus 0, secundigravida gravida 2, G2:.

The patient denies having abortions and states that her menstrual health has been superb with no complications whatsoever.

Personal/Social History: the patient is engaged, having one sexual partner. Her husband is an Electrical Engineer. They live together with her fiancée. Economically she is well off. They regularly go for routine checkups. Her husband is on diet.

Health Maintenance: her diet is supplemented with vitamins. She integrates vegetables and fruits on her diet. The last test on Pap smear recorded positive results, indicating she had minor cervical cancer. However, she was on medication and the cancerous cells were allegedly killed.

Immunizations History: Last HPV vaccine recorded in July.

Significant Family History: Both her parents are alive and she traces no sign of cancer or any other chronic disease in the past three generations

REVIEW OF SYSTEMS (ROS):

General: She appears perfectly healthy.

Skin: She has tender, soft and moist skin.

HEENT: She has an upright head and responded pupils. Oral mucosa is wet, and the oropharynx is clear, and the nasal passage is clear without any abnormalities

Neck: she has a normal neck range of motion of about 40 to 80 degrees without experiencing pain, discomfort and resistance

Breasts: She denies any abnormality in the breasts..

Respiratory: Normal.

Cardiovascular/Peripheral Vascular: No chest pains.

Gastrointestinal: she has healthy gastrointestinal that is well lubricated

Genitourinary: No abnormalities

Musculoskeletal: the alignment of muscles, tendons and bones is normal

Psychiatric: totally fine

Neurological: Safe with no complications.

Hematologic: Absolutely no problem in the blood.

Endocrine: thyroid glands and adrenal glands recorded no abnormality

Allergic/Immunologic: she denies having any hypertensive reaction to food, chemicals and weather variations. The immune system is functioning normally as she has undergone all necessary vaccinations

OBJECTIVE DATA:

PHYSICAL EXAMINATION

Physical Exam: normal Vagina, with pinkish discharge.

Vital Signs: temperature -96.5, pulse- 79, respiratory -17 blood pressure 111/73 mmHg, height-62 inches, weight -72.7 kg.

General: She appears healthy. She has a long and gloomy face due to pain. She has no normal gait due to the pain in the vulva and swelling. She is well-groomed. There is Adour due to vaginal discharge. She appears troubled and deep in thought.

HEENT: wet oral mucosa

Neck: Normal neck

Chest: Normal

Lungs: normal and unaffected

Heart: patients records no abnormalities on the heart

Peripheral Vascular: no abnormal signs.

Abdomen: absolutely normal

Bladder: the two sphincter muscles are functional.

Vagina: vagina walls are red due to discharge, well shaven pubic hair

Cervix: the cervix is slightly damaged due to the growing cancerous cells.

Uterus: normal

Adnexa: normal.

Rectum: norma

Musculoskeletal: musculoskeletal pain denoted at the vagina tissue.

Neurological: Normal

Lymph Node: they appear swollen

Skin: the skin is perfect.

LAB/DIAGNOSTIC TESTS AND RESULTS

The Pap smear results were, unfortunately, positive Vaginal culture is pending, results to be analyzed at a later date. Urinal STD panel tested positive

ASSESSMENT

Differential Diagnosis (DDx):

1. Bacterial vaginosis (BV): it is caused by lactobacilli bacteria in the vagina. It occurs when the level of lactobacilli gets low in the body. It’s an overgrowth in the vagina. It’s characterized by thick or whitish discharge or one that is slippery and clear. It causes itching and burning sensation. Fishy odor may be noticed during intercourse.

2. Trichomonas’s: it’ also called as trichomonas’s and is a sexually transmitted infection. It’s caused by single-celled trichomonas vaginalis and transmitted through intercourse. Symptoms include; burning, irritation, redness and swelling of the vulva with a yellow-gray or greenish vaginal discharge with fishy odor (Fantasia, 2017).

3. Gonorrhea: it’s a highly contagious sexually transmitted infection. The symptoms include; vaginal discharge, pain during urination and pain during vaginal sex.

FINAL DIAGNOSIS:

Cervical Cancer.

Caused by an infection with Human papillomavirus (HPV) Cancer is very preventable as it grows slowly.IN the case of early diagnosis. The patient showed all the symptoms of cervical cancer in its first stage.

PLAN:

Referrals- The doctor did a laser surgery in order to destroy the pre-cancerous cells. This was done carefully in order not to kill the surrounding healthy cells. A follow up examination was recommended for a period of 6 months with Pap smear after laser ablation to ensure all the cancerous cells are gone.

Health Promotion: She should have foods with enough calories and proteins. She should also have minor physical practices and quit smoking and alcohol intake.

Treatment: A consistent pelvic examination and pap smears as she has been diagnosed with cervical cancer.

Disease Prevention: To prevent the disease, the patient should avoid exposure to HPV by abstaining from sex or having protected sex with a barrier, like Condom). In addition to that quitting smoking would reduce possibility of exposure.

Follow up: weekly routine checkups with the gynecologist

Health promotion: patient advised having pep exam tests after every one year.

Holistic care: doctor recommended for long-course cervical therapy

Reflection

After thorough research and examination, I diagnosed the patient with cervical cancer. Further examination made me realize that the cancer is still its initial stages, increasing the possibility of cure and chances of survival.

References

Dasari, S., Wudayagiri, R., & Valluru, L. (2015). Cervical cancer: Biomarkers for diagnosis and treatment. Clinica chimica acta, 445, 7-11.

Glick, S. B., Clarke, A. R., Blanchard, A., & Whitaker, A. K. (2012). Cervical cancer screening, diagnosis and treatment interventions for racial and ethnic minorities: a systematic review. Journal of general internal medicine, 27(8), 1016-1032.

Schiffman, M., Castle, P. E., Jeronimo, J., Rodriguez, A. C., & Wacholder, S. (2007). Human papillomavirus and cervical cancer. The Lancet, 370(9590), 890-907.

Waggoner, S. E. (2003). Cervical cancer. The Lancet, 361(9376), 2217-2225.