Walden University Bacterial Vaginosis and Ectopic Pregnancy Discussion Response

Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests or treatment options your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position.

Patient Information:

Initials: T.S. Age: 58 Sex: Female Race: African American


CC (chief complaint): “Brown discharge for several days.”

HPI: This 58-year-old, A.A. female presents with complaint of brown discharge for several days. The symptoms started last week and is described as minimal to moderate. She is having to wear a pad to avoid soiling her clothes. She denies any pain with this discharge and has not tried any treatment to stop it. She reports is in menopause with last menstrual period 6 years ago. She is nulliparous. She denies nausea, fatigue, or fevers.

Current Medications:

  1. Glipizide 5 mg daily; Started 25 yrs ago for diabetes mellitus type 2 (DMT2).
  2. Metformin 1000 mg twice daily; Started 26 yrs ago for DMT2.


  1. No drug allergies
  2. No environmental allergies
  3. No food allergies



  1. Tdap 11/2/20;
  2. Influenza 10/16/21;
  3. Covid 19 #1 5/12/21, #2 6/23/21, #3 12/11/21 (Moderna).


  1. DMT2- somewhat controlled with oral medications, last A1C 7.5.
  2. Infertility-never able to get pregnant.

Soc & Substance Hx: Patient works as bank teller for local bank. She is widowed with no children. She is involved with activities in her church and enjoys helping in the nursery. She denies ever smoking, drinking, or illicit drugs. She lives in her family home and reports working smoke detectors. She reports a healthy support system of family and church friends.

Fam Hx:

  1. Maternal Grandfather-Deceased age 48, car accident.
  2. Maternal Grandmother-Deceased age 80, kidney failure. DMT2, HTN
  3. Paternal Grandmother-Deceased age 86, HTN
  4. Father-Alive age 79, HTN, high cholesterol, DMT2.
  5. Mother-Alive age 78, High cholesterol, HTN, chronic edema
  6. Brother -Alive age 55- healthy
  7. Sister- Alive age 53- cervical cancer.

Surgical Hx: Colonoscopy 1 year ago=normal results

Mental Hx: Denies any diagnosis of mental health related conditions. Denies suicidal or homicidal ideations.

Violence Hx: She denies any concerns of violence in her neighborhood. She lives alone, not in a current relationship.

Reproductive Hx: Menses start age 12, LMP 6 yrs ago. G0P0. No contraception use, not currently sexually active. Identifies as female, only male sex partners, vaginal intercourse. No history of sexually transmitted illnesses (STI).


GENERAL: Denies weight loss, fever or chills.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, pressure, or discomfort. Denies palpitations or edema.

RESPIRATORY: Denies shortness of breath, or cough.

GASTROINTESTINAL: Denies changes in eating, abdominal pain, bowel elimination, or dark stools. Last reported BM this am.

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Denies incontinence of bowel or bladder.

MUSCULOSKELETAL: Denies muscle, joint, or bone pain.

HEMATOLOGIC: Denies anemia history or bruising easily.

LYMPHATICS: Denies enlarged lymph nodes. Denies history of splenomegaly.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies heat or cold intolerance. Endorses DMT2 history, denies polydipsia, polyuria, or polyphagia.

GENITOURINARY/REPRODUCTIVE: Denies burning with urination. Endorses vaginal bleeding. Denies breast lumps or tenderness. Last Mammogram 1 yr ago, normal results. Last pap 2 years ago, NILM HPV negative, atrophic changes, no endocervical cells noted.


Physical exam:

VITAL SIGNS: Ht: 66 inches, Wt: 272 lbs, BMI 43.90 (morbid obesity). T 98.1, BP 140/88, HR 82, RR 12.

GENERAL: Pleasant, well-nourished female, A/O to person, place, time, and situation. Appears comfortable.

CHEST: Symmetrical rise and fall of right and left side chest. No extra work of breathing. LS clear throughout bilaterally posterior.

CARDIAC: RRR, S1 S2, no gallop, murmur, click, or rub. Pulses 2+ bilateral pedal and radial. No edema noted.

ABDOMEN: Soft, obese, active bowel sounds x4.

VVBSU: Brown discharge noted.

CERVIX: Brown blood from os, no CMT

Uterus: Unable to assess due to body habitus.

Adnexa: Unable to assess due to body habitus.

Diagnostic results:

  1. CBC- CPT 85025- This test will monitor for anemia and provide a baseline if the bleeding continues.
  2. Endometrial biopsy- CPT 58120- This test will collect tissue from the endometrium of the uterus for cytology, is easily done in the office, pain managed with ibuprofen, and is more cost efficient than other diagnostic tests (Will, & Sanchack, 2021).


Primary and Differential Diagnoses

  1. Uterine atrophy-N85.8- this is her primary diagnosis because of the presenting symptoms of brown blood, pap test with atrophy changes, and the patient’s report of not being able to get pregnant suggesting a condition like PCOS. Lack of estrogen, such as during menopause, causes atrophic changes to the vagina and the endometrium, which can lead to a state of chronic inflammation and bleeding (Sung, & Abramovitz, 2022).
  2. Adenomyosis-N80.0- Adenomyosis is a differential diagnosis because even though it fits, there is more information that is needed to confirm the diagnosis. The patient has postmenopausal bleeding and infertility which are both symptoms associated with adenomyosis, however, pain and heavy bleeding are also symptoms which the patient does not appear to have (Bourdon et al., 2020).
  3. Endometrial Cancer– C54.1- This differential diagnosis is relevant to this patient because of her family history of reproductive cancer in her sister, and her obesity. Endometrial cancer is more common in women in higher resource areas like the United States, and who have a sedentary lifestyle and obesity (Schuiling, & Likis, 2022, p. 583).


Therapeutic/non-therapeutic: Bleeding from uterine atrophy will likely stop on its own without treatment, but can be treated with topical and oral hormones (Sung, & Abramovitz, 2022). If she is not having pain, hormone replacement oral therapy would not be considered with this patient due to her family history of cervical cancer. Homeopathic interventions would likely only treat the vaginal atrophy. Counseling about options for hysterectomy if bleeding increases or starts effecting quality of life. Start Lisinopril 10 mg po daily for HTN.


  1. OB/GYN for surgical consult if wanting hysterectomy.
  2. Cardiologist if HTN persists after treatment


  1. Routine labs of CBC, CMP, Lipids, and A1C should be performed regularly, yearly for all except A1C which would be every 3-6 months depending on glycemic control.
  2. Depending on the results from the uterine biopsy, an ultrasound may be warranted to further diagnose changes and to rule out uterine fibroids.

Health Promotion: BMI management with diet and exercise modalities to help control blood sugars, increase mobility, decrease heart disease risks.


  1. Your bleeding is likely caused from atrophic changes to the uterus lining from menopause and decrease estrogen. Conservative treatment is the most recommended for this type of bleeding. If testing show otherwise then options will be discussed at follow up appointment.
  2. Your test results will be called to you when they return.
  3. You are being started on a blood pressure pill. It is recommended that you keep a blood pressure log and bring it with you to your next appointment.
  4. Call the clinic with any questions or concerns, especially if bleeding turns to bright red and increases.

Disposition: F/U in 2 weeks for blood pressure check and uterine bleeding.


This case study is a common situation that I have seen in my clinical rotation. Two cases come to mind, but both of those had heavy frank bleeding with severe pain. Both cases an endometrial biopsy was the initial step to reach a diagnosis. What I have learned from this case study and from clinic rotations, is to always consider cancer with abnormal bleeding, but less critical diagnoses should not be overlooked. Choosing tests that will provide the least amount of cost and pain, but provide diagnostic results is important to women’s health.


Bourdon, M., Santulli, P., Jeljeli, M., Vannuccini, S., Marcellin, L., Doridot, L., Petraglia,

F., Batteux, F., & Chapron, C. (2020). Immunological changes associated with

adenomyosis: A systematic review. Human Reproductive Update, 27(1), 108-

129. https://doi.org/10.1093/humupd/dmaa038

Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Chapter 29, pp.

569-600. Jones and Bartlett Learning.

Sung, S., & Abramovitz, A. (2022, May 1). Postmenopausal bleeding. In: StatPearls

[Internet]. Treasure Island, FL: StatPearls Publishing. https://www.ncbi.nlm.nih.


Will, A. J., & Sanchack, K. E. (2021). Endometrial biopsy. In StatPearls [Internet].

Treasure Island, FL: StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/N


Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests or treatment options your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position.