A Patient With Bleeding: A Nursing (SOAP) Note

Topic: Nursing
Words: 2074 Pages: 7

Patient Information

ST, 62, female, African American.

CC: The patient reports that she has continuous vaginal bleeding that stops and starts again for the past three months.

HPI: ST is a 62-year-old African American female patient who attends the clinic as a referral from Dr. Johnson, her PCP. Today, she presents for a standard annual exam during which she reports having some continuous vaginal bleeding off and on with some clear discharge for the past three months. The patient admits that the bleeding may start accidentally, last for a few hours, and stop coming back several days later – however, there is no specific pattern of this condition. She describes it as bright red and light flow with no pain, clots, or cramping. The patient is married for many years and has a permanent sexual partner. At the same time, she states that has not been sexually active for 2 years due to pain and discomfort during intercourse. The patient denies pelvic pressure, dyspareunia, urinary urgency, frequency, and post-void dribbling. In turn, she admits she has urine leaking while cough/sneeze/laugh. The patient reports she had a total hysterectomy 7 years ago.

Current Medications: Glucophage 500 mg PO bid (type 2 diabetes), Temazepam 10 mg pro re nata (insomnia), HCTZ 25 mg PO daily (high blood pressure), vitamin B complex PO daily (food supplement). The duration of all medications’ administration is more than 1 year.

Allergies: NKDA, no food or environmental allergies presented.

PMHx: The patient is routinely followed up by Dr. Johnson for primary care. All immunizations are up to date; the date of last tetanus is 4/2020. The patient’s total hysterectomy was 7 years ago, however, the patient cannot confirm whether the cervix and ovaries were removed as well. No other surgeries were made during the patient’s lifetime. Comorbid major illnesses include hypertension and type 2 diabetes – the patients’ condition in relation to these diseases is considered and controlled.

Soc & Substance Hx: ST is currently a householder; she had been working in the retail industry for 25 years. In the present day, she lives with her husband in a relatively small single-family home. The patient has 4 children and 10 grandchildren who live in surrounding communities and regularly visit her. Moreover, she has several good friends and meets them a few times per week for lunch or dinner. In general, the patient reports that she receives good support from her family and friends. She has two cats and one dog, interested in gardening, cooking, playing solitaire, and embroidering. The patient denies tobacco, alcohol, and drug use and pays particular attention to her health and safety – she always uses seat belts and never uses the mobile phone while driving, recycles domestic household waste, and has smoke detectors and a security system in her home.

Fam Hx: The patient’s siblings, father, and relatives from his side do not have inherited, contagious, or serious chronic illnesses. The father died at the age of 87 from natural causes. At the same time, similar to the patient, her mother had diabetes mellitus and related hypertension; she died from a heart attack. The patient’s grandmother from the mother’s side died from lung cancer she had had for 5 years. The patient’s children and grandchildren do not have a significant medical history and are relatively healthy.

Surgical Hx: Total hysterectomy 7 years ago.

Mental Hx: The patient does not report serious mental health disorders. She does not have a history of suicidal or homicidal ideation and/or self-harm practices. At the same time having type 2 diabetes and associated hypertension that may be regarded as relatively severe chronic diseases, the patient occasionally feels depressed due to the inability to enjoy life to the fullest extent, however, these expressions of depression and anxiety do not require medical intervention.

Violence Hx: The patient denies any issues related to her safety. No violence was previously experienced in her marriage.

Reproductive Hx: G4P4. The patient is in the post-menopause period, the date of LMP is approximately 2/2015. The patient is not pregnant, not nursing/lactating. The patient does not use any contraceptive method, however, she does not have any type of sexual intercourse due to discomfort and current pain.


GENERAL: No weight loss, weakness, fever, chills, or fatigue.

HEENT: Eyes: No visual loss, double or blurred vision, yellow sclerae. Ears, Nose, Throat: No hearing loss, congestion, runny nose, sneezing, or sore throat. The patient denies any changes in hearing and smell.

SKIN: The patient denies rash, itching, pruritus sore, or hirsutism.

CARDIOVASCULAR: No chest pressure, chest pain, or chest discomfort at the time of examination. No palpitations or edema.

RESPIRATORY: No cough, shortness of breath, or sputum at the time of examination.

GASTROINTESTINAL: No anorexia, bulimia, vomiting, nausea, or diarrhea. Extra weight. No abdominal deformation, pain, or blood.

GENITOURINARY: The patient denies burning or pain in urination. No pregnancy, post-menopause period, LMP: 2/2015.

NEUROLOGICAL: No headache, syncope, paralysis, dizziness, numbness, ataxia, or tingling in the extremities at the time of examination. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, joint pain, back pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No history of splenectomy. No enlarged nodes.

PSYCHIATRIC: No history of depression or anxiety, mental health disorders, homicide, suicidal attempts, or lack of safety and comfort.

ENDOCRINOLOGIC: No reports of heat intolerance, sweating, or cold. No polyuria or polydipsia. The patient has been diagnosed with type 2 diabetes, however, she follows up with Dr. Johnson, and her condition is controlled. The patient reports current fasting blood sugar as 90.

REPRODUCTIVE: G4P4-all vaginal births; the patient is currently not pregnant. She has continuous vaginal bleeding off and on with some clear discharge for the past three months. She describes it as bright red and light flow with no pain, clots, or cramping. The patient is in monogamous relationships with one partner, however, she reports the absence of intercourse for 2 years due to pain. The patient is in the post-menopausal period. Menarche was at 13; the intervals and duration of menstrual cycles were regular. The patient had a total hysterectomy 7 years ago at the age of 55.

ALLERGIES: No history of asthma, eczema, hives, or rhinitis.

Physical exam

Constitutional: No acute distress. The patient is alert and oriented. The patient is clean, has slight signs of obesity. and appears according to the stated age.

HEENT: Oral mucous membranes are moist. Eyes have equal round reactive pupils with normal visual fields by confrontation presented. Eyes appearance – bilateral with all related structures.

Lymph: No lymphadenopathy noted.

Chest: The inspection of the chest, the entire chest wall’s palpation of, the inspection of the breast, the palpation of the breasts, the inspection of the axillae, and the palpation of the axillae. are within normal limits; no changes or space-occupying lesions were detected. The patient’s chest is with symmetrical chest rise. ancillary lymphadenopathy was not detected. Nipples and areolae are without change.

Respiratory: Ventilation is stable; respiratory effort is normal. Lungs are clear bilaterally according to auscultation.

Cardio: Regular heart rate and rhythm; S and S2 present.

GI: The patient’s abdomen is non-distended, non-tender, and soft to palpation; no changes or space-occupying lesions were detected. Normal active bowel sounds present.

GU: Normal external appearance of the vagina and the appearance of the urethra; no CVA tenderness, color change, abnormal findings in the vagina area’s structure, or malformation. A bimanual exam of the vagina shows its normal palpation; no tenderness or masses were noted.

A speculum exam reveals malodorous and gray discharge from the vagina.

Neuro: A&Ox3 according to sensory and motor examinations

Psych: The signs of mental disorders were not detected.

Skin: Good skin turgor, no rash, lesion, neo-formations, or unusual color noted.

Diagnostic results

Pelvic exam with the laboratory examination of vaginal cultures to check for bacterial vaginosis, yeast, and STIs.

UA with cultures to detect bacteria.

Transvaginal Ultrasound to detect neo-formations.

Estrone or E, Lab-TSH, testosterone level test, CBC.

N95.2 – Postmenopausal Atrophic Vaginitis

Vaginal atrophy or postmenopausal atrophic vaginitis is the vagina walls’ thinning that leads to inflammation and associated itching, dryness, dyspareunia, burning, irritation, discharge, and pain. In general, vaginitis occurs due to the disbalance of bacteria and yeast typically presented in the vagina (Krapf, 2018). There are multiple risk factors that may cause vaginal atrophy, including particular skin disorders, inappropriate hygiene, irritating chemical substances that cause allergy, the ovaries’ surgical removal, sexually transmitted infections, hormonal changes, particular medications, and uncontrolled diabetes. However, postmenopausal atrophic vaginitis is primarily associated with “estrogen deficiencies during menopause that causes reduced vaginal secretions, vulvovaginal atrophy, and decreased glycogen production by vaginal epithelial cells” (Shen et al., 2016, p. 1). The most common signs and symptoms of this disease are light vaginal bleeding, pain during intercourse, odor, a change in discharge color, irritation or itching, spotting, and painful urination (Krapf, 2018). For the diagnosis of postmenopausal atrophic vaginitis, such informative methods as the pelvic exam and the examination of discharge are applied. The exam helps health care providers to detect skin thinning, cervical polyps, trauma, rectal and urethral pathologies, and abnormal vaginal or cervical growth (Krapf, 2018). In turn, odorous discharge may indicate the presence of infection.

A59.9 – Trichomoniasis

Trichomoniasis may be regarded as a common, sexually transmitted infection caused by the protozoan Trichomonas vaginalis that results in urethritis and vaginitis (Rein, 2020). This motile organism generally lives in females’ lower genitourinary tract and males’ urethra or prostate (Schumann & Plasner, 2018). In women, the symptoms of trichomoniasis may range from absent to severe pelvic inflammation. They traditionally include vulvovaginal burning, irritation, itching, or soreness, pain, and an abnormal frothy, odorous, or purulent vaginal discharge. For diagnosis, testing for Trichomonas vaginalis is recommended; in addition, testing for other sexually transmitted infections, such as gonorrhea and chlamydia, is essential due to its typical co-occurrence.

C52 – Vaginal Cancer

In the case of vaginal cancer, malignant cells form in a woman’s vagina (National Cancer Institute, 2020). Continuous postcoital and intermenstrual bleeding may be regarded as the most common symptom of vaginal cancer. Other signs include non-menstrual discharge, pain in the pelvic area and during sexual intercourse, pain when urinating, a lump in the vagina, and constipation (National Cancer Institute, 2020). The disease’s risk factors are older age (60 years or older), having a human papilloma virus (HPV) infection, and having a hysterectomy due to a tumor (National Cancer Institute, 2020). For the primary diagnosis of vaginal cancer, a pelvic examination is essential. Regular screening is highly efficient for the prevention of vaginal cancer as well, and despite the fact that it is cost-ineffective, patients at risk should receive it regularly.

Continuous irregular bleeding in the patient in her post-menopause period and with the history of a total hysterectomy requires further investigation. She reports vaginal bleeding and vaginal discharge that is supposed to irritate the vagina and lead to bleeding. In addition, having one partner, the patient cannot confirm that her husband did not have other sexual partners. That is why STI test will exclude the presence of sexually transmitted diseases. In addition, a vaginal ultrasound may detect the reason of bleeding.

Taking into consideration the patient’s age, menopause, hysterectomy, common symptoms, partner status, and type 2 diabetes, she likely has postmenopausal atrophic vaginitis that requires hormone therapy. Treatment may include vaginal estrogen cream, 1-2 g of which should be applied 3-7 times per week for three weeks with one week without it for several months (Krapf, 2018). In addition, it is essential to make colonoscopy and UA to make sure that bleeding is from the vagina and not from another source.

From a personal perspective, a suggested treatment may be regarded as highly effective. First of all, it focuses on the most probable diagnosis and includes various tests in order to confirm that other diagnosis may be excluded. At the same time, any treatment should correspond to the patient’s condition and peculiarities. Thus, if she was pregnant or just delivered, bleeding would require particular attention – it would be essential to confirm that bleeding is vaginal for an adequate response. In turn, if the patient reported domestic violence, a health care provider could consider trauma as a potential cause of bleeding. Nevertheless, health care facilities and the health care system should develop efficient methods of women’s gynecologic health promotion and disease prevention, especially among the older African American population due to its vulnerability and limited access to medical assistance.


Krapf, J. M. (2018). Vulvovaginitis treatment & management. Medscape. Web.

National Cancer Institute. (2020). Vaginal cancer treatment (PDQ®)–patient version. Web.

Rein, M. F. (2020). 100 – Trichomoniasis. Hunter’s Tropical Medicine and Emerging Infectious Diseases (Tenth Edition), 731-733. Web.

Schumann, J. A., & Plasner, S. (2018). Trichomoniasis. StatPearls Publishing, Treasure Island (FL),

Shen, J., Song, N., Williams, C. J., Brown, C. J., Yan, Z., Xu, C., & Forney, L. J. (2016). Effects of low dose estrogen therapy on the vaginal microbiomes of women with atrophic vaginitis. Scientific Reports, 6(24380), 1-11.

Virtual Visits and the Changing Role of a Nurse
Role of Palliative Care in Canada