Weekly Clinical Experience Discussion

Reply to Frantz

Weekly experience 5

Did you face any challenges, any success? If so, what were they?

   The week went in smoothly. We encounter many patients with different problems. My preceptor allows me to come with differential diagnosis, management, and treatment.

Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and possible differential diagnosis.  

     A 30-year-old woman comes to the clinic and reports for the past six months she as been having heavy and prolonged period. She also reports bleeding between periods, pelvic pain, and pressure. She reports for the last 2 months she has low back pain.

Examination:

 Physical Examination: After privacy was provided a pelvic examination was performed which allowed the physician to feel the size and shape of the uterus. An enlarged and irregularly shaped, of the uterus was noted which were indications that fibroids may be present. My preceptor then orders an ultrasound STAT.

BP: 130/78, Temp: 36.9, HR 80: RR 18, Pain:3

Differential diagnosis:

Pregnancy

Leiomyoma

Uterine adenomyoma or diffuse adenomyosis

Uterine sarcoma

Leiomyoma variant

Plan of Care: Uterine Fibroids

    Uterine fibroids are the most common gynecological disorder, classically requiring surgery when symptomatic. Although attempts at finding a nonsurgical cure date back to centuries, it is only around the middle of the last century that serious attempts at a medical treatment were carried out. Initially, both progestins and estrogen–progestin combinations have been utilized, although proof of their usefulness is lacking. Today, it is widely accepted that in subjects with asymptomatic uterine myomas who do not desire pregnancy, no special treatment is required, and these patients need only periodically monitoring of their condition. For this reason, the most conservative options that minimize morbidity/risk and optimize outcomes should be selected  (Manuela Farris, Carlos Bastienally, 2019).

Therapeutic:  Tranexamic acid 500mg 2 tabs 3 times a day for 4 days. May take with or without food.

Management/Education

    Evidence on medical treatments has been systematically analyzed in 2016 in a total of 75 randomized controlled trials (RCT), concluding that their overall quality was very low and that there was insufficient evidence to recommend any medical treatment in the management of fibroids (Manuela Farris, Carlos Bastienally, 2019).

Follow up in 3 months

Support your plan of care with the current peer-reviewed research guidelines.

    Classically, nonsteroidal anti-inflammatory drugs (NSAIDs) have been a regular solution for pain, in addition to hormones, either estroprogestins or progestogens, acting on the endometrium. In fact, the levonorgestrel intrauterine system (LNG-IUS) has become a success in gynecological therapy, and it is the reference for the progestin treatment. Although it does not act directly on the UFs, it reduces menstrual blood loss in women with this pathology. Therefore, it may be an excellent solution for mild and even severe bleeding when it is well tolerated. Tranexamic acid is a procoagulant drug that has also shown good results by reducing blood loss during menstruation, and it is particularly useful in women with UFs who have mild bleeding. It is only prescribed for 3 or 4 days per month and its dose may be adaptable according to each woman’s needs. It is usually well tolerated with few side effects (Mas, 2017).

References

Manuela Farris, Carlos Bastienally. (2019). Uterine Fibroids: An update on current and emerging medical treatment options. Therapeutics and Clinical Risk Management, 15:157-178doi: 10.2147/TCRM.S147318.

Mas, A. (2017). Updated approaches for management of uterine fibroids. International Journal of Women’s Health, 9:607-617 doi: 10.2147/IJWH.S138982.