Diagnosis of Uterine Fibroid Discussion Paper

Please choose a gynecological disease process from your practicum experience or your professional practice that would be quite challenging for you as a clinician I do not have to approve your case study.  Please make sure that the listed objectives are met to avoid point deductions.

• 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 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 the Focused SOAP Note Template found in the Learning Resources to support Discussion. Diagnosis of Uterine Fibroid Discussion Paper

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Case study:

Diagnosis is Uterine Fibroid

Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your clinic today to discuss contraceptive options. She states that she is not interested in having more children, but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her
social history is negative for alcohol and tobacco; she reports daily marijuana use. She has no
known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. Family
history reveals that her maternal grandmother is alive with dementia, while her maternal
grandfather is alive COPD. Her paternal grandparents are both deceased due to an automobile
accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a
history of skin cancer (basal cell). Elaine has one older sister with endometriosis who was told
not to have more children because she had blood clots when she was pregnant with her second
child. She also has one younger brother with no reported medical problems.
· Height 5’ 7” Weight 148 (BMI 23.1) BP 118/72 P 68
· HEENT: wnl
· Neck: supple without adenopathy
· Lungs/CV: wnl
· Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge
· Abd: soft, +BS, no tenderness Diagnosis of Uterine Fibroid Discussion Paper
· VVBSU: wnl,
· Cervix: firm, smooth, parous, without CMT
· Uterus: mid, mobile, non-tender, approximately 8 cm,
· Adnexa: without masses or tenderness
QUESTION:
What additional information do you need?

UPDATE
Elaine states that her cycles come every 28-32 days, for a duration of 5-8 days, and on her
heaviest day she must use a super tampon every hour and get up to change her pad 2-3 times
at night. Her last gyn exam was one year ago and she shows you a copy of the results on her

patient portal. The results for the pap were NILM, HPV negative, and her cultures for GC/CT
were negative.
In further questioning, you ask her about her sister’s blood clots and her father’s PE. She
shares that her father was 48 years old and “just died one day.” Her sister was on “shots” for her
blood clots and then took a pill. She had some blood test done and they said she had something Diagnosis of Uterine Fibroid Discussion Paper
called heterozygous MTHFR and Factor V Leiden.
She has heard about a pill where she will only get her period four times a year and feels now that she’s older she can remember to take the pill daily and plans on putting a reminder in her
phone.

Please choose a gynecological disease process from your practicum experience or your professional practice that would be quite challenging for you as a clinician I do not have to approve your case study. Please make sure that the listed objectives are met to avoid point deductions.

• 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 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 the Focused SOAP Note Template found in the Learning Resources to support Discussion.

See Attached for SOAP Note Template and Case Study Diagnosis of Uterine Fibroid Discussion Paper