Identifying Data

Time: 10/16/19

Name: F.C.

Sex: Female

Age: 78 years old

Nationality: Hispanic

 

Chief complaint: “I am here for my biopsy”

 

HPI:

78-year-old G0P0 female with PMHx of glaucoma and HTN presents to the outpatient OBGYN clinic for an endometrial biopsy. LMP was at age 48. On 8/5/19 pt was seen at Woodhull ED for hematuria and was diagnosed with a UTI, r/o vaginal bleeding. Pt was seen in clinic for follow up on 10/2/19, at which point all symptoms had resolved. Pelvic US was performed, which showed an endometrial thickness of 2mm. Pt was then instructed to return today for endometrial biopsy. Currently, pt denies any complaints. She states that she was never bleeding from her vagina, it was only “a little” in her urine. Pt states that the UTI resolved within several days of her ED visits, after she was started on an antibiotic. She does not recall the name of the antibiotic. Pt denies abnormal vaginal bleeding, vaginal discomfort, abnormal discharge, dysuria, hematuria, frequency, weight loss, CP, palpitations, HA, dizziness, abdominal pain, nausea, vomiting, diarrhea, constipation, family history of ovarian, uterine or vaginal cancers. Pt is not sexually active

 

DDX:

• Endometrial carcinoma
  • Consistent with possible postmenopausal vaginal bleeding
• Hematuria secondary to UTI
  • Consistent with previous diagnosis of UTI and patient’s claim that the bleeding was not from her vagina.

 

Past medical history:

• Glaucoma
• HTN

Past hospitalizations: denies

Past surgeries: denies

Immunizations: up to date

Allergies: denies environmental, food and drug allergies

 

Medications:

Losartan 100mg QD

Melatonin 3mg HS PRN

Metoprolol tartrate 50mg BID

Propylene glycol 0.6% solution ophthalmic administer 1 drop in both eyes two times a day as needed

 

Family history:

Denies family history of ovarian, uterine, vaginal or breast cancers. Otherwise non-contributory

 

Social History:

F.C. is a single female living alone in an apartment. She is a retired schoolteacher.

Habits: Pt denies ever smoking cigarettes, drinking alcohol or illicit drug use.

Travel: denies

Sexual history: Pt is not sexually active, 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. Last mammogram December 2018.

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

Cardiovascular: Denies chest pain, 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: Denies vaginal bleeding or clots, pain or discomfort, unusual discharge. LMP age 48.

Sexual Activity: denies being 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: Patient in no acute distress, average height and weight, appears stated age, well nourished, good hygiene, good posture, A/Ox3.

 

Vital signs: BP 138/83, HR 86 BPM regular, RR 17 unlabored, O2 98% room air, Temp 98.0 F (oral), weight 135lb, Height 5’1”

 

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

 

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

Visual fields full OU. PERRL, 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.

 

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

 

Mouth: mucosa pink, moist, no evidence of masses or lesions. Injected oropharynx, no evidence of exudate or inflammation.

 

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/Lungs: Symmetrical, no deformities, respirations unlabored. Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No adventitious sounds. Lat to AP diameter 2:1.

 

Beast: no chest deformity or asymmetry. Normal contours. no nodules, masses, tenderness, axillary adenopathy or nipple discharge bilaterally.

 

Abdomen: Flat, symmetrical, no evidence of scars, 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.

 

Pelvic: vulva atrophic, no masses, lesions or inflammation noted. Vaginal mucosa pale and atrophied with no bleeding or discharge. Cervix with pinpoint os. No masses or lesions. No adnexal tenderness.

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

 

Labs/imaging:

• UA: WNL
• Pelvic US (9/24/19): “fluid and soft tissue in endometrium approximately 2mm, exclusive of fluid. Ovaries not enlarged- normal findings”

 

Procedure note: endometrial biopsy attempted. Unable to pass uterine sound past pinpoint os. Pt displayed extreme discomfort. Procedure abandoned.

 

DDx:

• UTI, resolved:
  • Consistent with previous diagnosis of UTI and patient’s claim that the bleeding was not from her vagina as well as normal pelvic US
• Endometrial cancer
  • Consistent with post-menopausal bleeding. But normal pelvic US and pt persistent denial of vaginal bleeding makes it less likely
• Vaginal atrophy leading to mild spotting/bleeding
  • Patient displayed vaginal atrophy on exam. Vaginal atrophy is consistent with normal pelvic US and may cause vaginal bleeding secondary to vaginal irritation.

 

Assessment:

78-year-old G0P0 female with PMHx of glaucoma and HTN presented for an endometrial biopsy secondary to UTI and hematuria, r/u postmenopausal bleeding. Pelvic US showed endometrium approximately 2mm. Pt denies any vaginal bleeding. Endometrial biopsy was unsuccessful secondary to pinpoint os. Presentation consistent with hematuria secondary to UTI, which is now resolved.

 

Plan:

Resolved UTI, r/o postmenopausal bleeding:

• Given US findings of 2mm endometrial lining and patient’s persistent denial of vaginal bleeding, there is a low suspicion for endometrial pathology.
• f/u pelvic US in 6 months, will reevaluate need for biopsy then.
• return to clinic if there is any change in vaginal discharge or new onset bleeding or pain. Go to ED if there is any heavy vaginal bleeding.

 

Glaucoma:

• continue using eye drops as prescribed

HTN:

• continue taking Losartan and metoprolol as prescribed
• low salt diet

 

Patient Education:

Because you have never had any children, the opening in your cervix is very small which did not allow us to complete the biopsy of the lining of your uterus. This being the case, if we wanted to try for another biopsy it would need to take place in the OR. When someone has endometrial cancer, the ultrasound will generally show a thickened uterine lining. Your uterine lining was not thickened. This combined with the fact that you don’t think you ever had any vaginal bleeding makes it very unlikely that you have endometrial cancer. Not having any kids is a risk factor for endometrial cancer. Because of this, we will get another pelvic US in 6 months. If the US shows no thickening of your lining, then there is no reason for concern. If it does reveal a thickened lining, then we will proceed with the biopsy. For now, there is no reason for concern. If you do experience vaginal bleeding, make another appointment or head to the emergency room.