Identifying Data

Date: 4/23/19

Name: A.S.

Sex: female

Age: 83 years old

Race: African American

Nationality: American

Marital status: Widowed

Location: Queens Hospital Center

Source of information: Self

 

Chief Complaint: “when I went to the bathroom this morning, I saw a lot of blood” x4 hours

 

HPI:

83-year-old female with PMHx of HTN, DM s/p hysterectomy, was brought in by EMS with vaginal bleeding. Pt states that when she went to the bathroom at 4am she saw blood and clots. She immediately called 911. Pt had hysterectomy 8 years ago for prolapsed uterus, and had a pessary placed. The pessary was last changed 2 years ago, pt has not seen GYN in the past 2 years. Pt states this has never happened before. Pt states the bleeding has been consistent since 4am but denies any pain. Pt is unsure whether cervix was removed during hysterectomy. Pt denies nausea, vomiting, diarrhea, fever, dysuria, chills, hematuria, urgency, dizziness, SOB, LOC, abdominal pain, recent weight loss, night sweats.

 

DDx:

• Vaginal/cervical cancer
  • Patient is 83 years old, s/p hysterectomy with significant vaginal bleeding
• Erosion from pessary
  • Pessary has not been removed for 2 years, it may have caused damage to vaginal canal over that time.

 

Past Medical History:

• DM x50 years
• HTN x25 years

Past Hospitalizations: see surgeries

Past surgery: Hysterectomy for prolapsed uterus- 2011, no complications

Immunizations: up to date

Allergies: denies Environmental, food and drug allergies

 

Medications:

Losartan Potassium & hydrochlorothiazide 110-25mg QD

Metformin 850mg BID

 

Family History:

Non-contributory- no family history of vaginal, uterine, breast or cervical cancer

 

Social History:

A.S. is a widowed female living with an aid. She is retired for 15 years.

Habits: denies drinking alcohol and smoking cigarettes

Travel: none

Diet: A.S. reports eating healthy most days, cheats with cookies or ice cream occasionally

Exercise: walks around the block 2-3x/week

Safety measures: admits to wearing a seatbelt

Sleep: 5-6 hours/night

Sexual history: has not been sexually active since death of husband 10 year ago. Denies history of STIs

 

Review of Systems:

General: Denies fatigue, weakness, chills, fever, loss of appetites, fever, night sweats, recent weight loss or gain.

Skin, hair, and nails: denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritis and changes in hair distribution.

Head: Denies headache, vertigo, head trauma, unconsciousness, coma, fracture.

Eyes: denies wearing glasses or contacts, visual disturbances, fatigue, lacrimation, photophobia or pruritis.

Ears: denies deafness, pain, discharge, tinnitus, and hearing aids

Nose/sinuses: denies discharge, epistaxis, and obstruction

Mouth and Throat: Denies sore throat, bleeding gums, sore tongue, mouth ulcers, voice changes, or dentures.

Neck: denies localized swelling/lumps, stiffness/decreased range of motion

Breast: Denies tenderness lumps, nipple discharge

Pulmonary System: Denies dyspnea, orthopnea, SOB, PND cough, wheezing, hemoptysis and cyanosis.

Cardiovascular: Denies CP, HTN, edema, palpitations, irregular heartbeat, and syncope.

Gastrointestinal system: denies decreased appetite, intolerance to foods, nausea, vomiting, hemorrhoids, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, constipation, rectal bleeding, blood in stool, pain in flank

GYN: Admits to vaginal bleeding and clots, denies pain or discomfort, unusual discharge. LMP age 53.

Sexual Activity: not sexually active

Nervous: Denies headaches seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system: Denies muscle/joint pain, deformity of swelling, redness or arthritis

Peripheral vascular system: Denies varicose veins, peripheral edema, intermittent claudication, coldness or trophic changes, or color change

Hematological system:  Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric: Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional

 

Physical Exam

General: Elderly female, average height and weight in an obvious state of concern, no signs of pain or discomfort. Pt is neatly groomed, looks stated age, good hygiene, good posture, A/O x3.

 

Vital Signs: BP 143/86, P: 96 BPM regular, T: 98.2 F, O2: 98% room air, RR: 16 unlabored

 

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.
Hair: average quantity and distribution.
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: normocephalic, atraumatic, non-tender to palpation throughout.

Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear

Visual fields full OU. PERRLA, EOMs full with no nystagmus.

Ears: Symmetrical and normal size. No evidence of lesions/masses/trauma on external ears.
No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/intact with light reflex in normal position AU.

Nose: Symmetrical, no obvious masses/lesions/deformities/trauma/discharge.

 

Lips: Pink, moist; no evidence of cyanosis or lesions.
Mucosa: Pink; well hydrated. No masses; lesions noted.

Palate: Pink; well hydrated. Palate intact with no lesions; masses; scars. Teeth: no visible caries
Gingivae: Pink; moist. No evidence of hyperplasia; masses; lesions; erythema or discharge. Tongue: Pink; well papillated; no masses, lesions or deviation noted.

Oropharynx: Injected oropharynx; well hydrated; no evidence of erythema, inflammation, exudate; masses; lesions; foreign bodies. Tonsils present with injection. Uvula pink, no edema, lesions.

 

Neck: Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM.

Heart: PMI in the 5^th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruit. RRR. S1 and S2 are present. No S3, S4, splitting of heart sounds, or murmurs present.

Chest: symmetrical, no deformities, no evidence of trauma. Respirations unlabored/no paradoxical respirations or use of accessory muscles notes. Lat to AP diameter 2:1.

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No adventitious sounds.

Abdomen: Flat, symmetrical, no evidence of striae, caput medusae or abnormal pulsations, BS present in all four quadrants. Non-tender to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally. 5-inch vertical scar noted below umbilicus- attributed to hysterectomy, scar is well healed, no signs of infection.

 

Extremities: Full range of motion, no edema, erythema, or deformities. Pulses intact throughout. No clubbing or cyanosis. Capillary refill <2 seconds throughout.

 

Pelvic: Copious blood and quarter sized clots in vaginal vault, cervix could not be visualized. No obvious lesions or masses. Bleeding was continuous, source could not be identified.

 

Neurological: A/O x3, no signs of dizziness of confusion.

 

Initial labs:

• HGB: 8.4
• T/S
• CBC, BMP- WNL

 

GYN consult: Pessary was removed, behind it were two disk shaped blood clots, 3 inches in diameter, large amount of blood was removed. GYN determined that cervix was removed during hysterectomy. Upon further inspection a 3×2 cm ulceration visualized 3 o’clock in vaginal vault. There was no active bleeding at erosion site.

 

Progress note: Pt admits to dizziness and confusion. Pt is unable to keep eyes open for more than a couple of seconds. There is evidence of acute mental status changes, likely due to the acute blood loss.

 

Repeat Labs:

• CBC, VBG, coags, T/S- WNL
• HGB: 7.4

 

DDx:

• Erosion secondary to pessary
  • Consistent with 2x3cm erosion visible once pessary was removed and the fact that the pessary hasn’t been cleaned or changed for the past two years.
• Vaginal cancer
  • Consistent with vaginal bleeding and vaginal erosion in a 83 year old, post-menopausal female.
• Uterine cancer
  • This would be high on the list of differentials for a post-menopausal female presenting with copious vaginal bleeding. It is unlikely in this patient due to history of hysterectomy

 

Assessment:

83-year-old female with a PMHx of HTN and DM presents with vaginal bleeding and large clots since 4am. Physical exam revealed 2×3 cm erosion in vaginal vault. Presentation consistent with erosion secondary to long term pessary placement.

 

Plan:

Vaginal Bleeding:

-blood transfusion- 2 units

-continue to monitor HGB/HCT, and signs of mental status changes, dizziness, loss of consciousness.

-Pelvic US to rule out pelvic mass

-Admit to EDOU for overnight observation

-Refer to outpatient GYN for continued care

-repeat labs Q4-6 hours

-Keep on telemetry and monitor vitals Q4h

 

DM:

-Provide pt with low carb diet during hospital stay

-Continue current medications as directed

-Monitor blood glucose QAC

 

HTN:

-Provide low salt diet while at during hospital stay

-Continue current medications as directed

 

Patient Education:

Pessaries must be changed between 1 week to 3 months. It is likely, that because your pessary was not removed for the past 2 years it eroded into your vaginal wall leading to the bleeding. It is likely that you have been bleeding for a while, but the pessary caused the blood to clot and therefore you didn’t realize what was going on. Right now, you are not actively bleeding. We gave you a blood transfusion because you lost a lot of blood which is why you because dizzy and drowsy. Because blood transfusions can have side effects, we are going to keep you in the hospital overnight for observation. Before you leave, we are going to set you up with a GYN, it is very important that you make an appointment as soon as you are discharged. Even though the erosion is most likely because of the pessary, they are going to want to make sure nothing else is going on. For the future, if your GYN decides to put in a new pessary, it is very important to get it changed regularly to prevent any erosions and to keep you from having to go through this again.