NRNP 6552 Week 3: Case Study Discussion: Gynecologic Health

Episodic/Focused SOAP Note Template

Patient Information:

SL, 24yo, F, Caucasian

CC: Vaginal Bleeding

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HPI: Susan Lang is a 24-year-old Caucasian female presenting to the clinic complaining of bleeding after intercourse. Susan relates she has been having some post-coital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies.

Current Medications:

Tylenol PRN fever

Midol PRN menstrual cramping

Allergies:

Denies medication, latex, and environmental

PMHx: Denies

Immunizations:

Childhood immunizations UTD

Last Tdap: 9-2022

Soc & Substance Hx: Cigarette smoking at a rate of ½ PPD since age 14. ETOH only on weekends, 6-8 hard liquor. Daily marijuana smoking.

She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen.

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Fam Hx: Non-contributory

Surgical Hx:Denies

Reproductive Hx: Onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily.

ROS:

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

HEENT: Sore throat x 3 weeks.

HEMATOLOGIC: Post-coital bleeding x 6 weeks

LYMPHATICS: 1-2 day fever

GENITOURINARY/REPRODUCTIVE: Post-coital bleeding x 6 weeks

Temp 97.8 oral, pulse 68, BP 112/64 sitting, height 5’6” and weight 118 lbs. BMI 19.04

HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened.

Lung: clear to auscultation

CV: regular sinus rhythms without murmur or gallop

Abd: soft, non-tender, liver normal,

Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.

VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted

Cervix: friable, some petechia no cervical motion tenderness.

Uterus: mid mobile, non-tender

Adnexa: without masses or tenderness

Perineum: wnl

Rectum: wnl

Extremities: full rom, skin clear, no edema, reflexes 1+.

Neurological: CN II-12 grossly intact.

My differential diagnosis for this patient is cervicitis. Cervicitis is defined as inflammation of the cervix. Females diagnosed with this condition can present as asymptomatic or have complaints of pain during intercourse, vaginal discharge, and/or vaginal bleeding that occurs after intercourse or between menstrual cycles (Mau & Lewis, 2022). These symptoms usually occur from injury, inflammation, or irritation to the cells of the cervix (Mau & Lewis, 2022).

Additional questions I would ask this patient include:

What days did you develop a fever?

What was your temperature reading?

Is your sore throat constant or off and on? Is your throat pain worse with swallowing?

What is your partner’s gender?

How many partners are you currently sexually active with?

When was the last time you had sexual intercourse?

How many times in the past 6 weeks have you had sex?

What types of sexual acts do you participate in oral, vaginal, and or anal?

Have you ever been diagnosed with an STI? If so, when were you diagnosed? what was the diagnosis? What were your symptoms?

When were you last diagnosed with an STI?

Did you receive treatment?

When was your last menstrual period?

What symptoms do you experience with your menstrual period?

What is your normal menstrual flow?

Do you use pads and or tampons during your menstruation? How many do you use in a day?

What products or douches do you use in the vaginal area?

Are you having any pelvic pain?

Any vaginal discharge?

Any vaginal itching?

Are you experiencing any abnormal vaginal odor?

How many days do you bleed after intercourse?

How many pads do you go through after intercourse?

Is your bleeding bright red after intercourse?

Is intercourse painful?

Has your partner told you they are currently positive for any STIs?

Are you and your partner exclusive?

When was your last pelvic exam? What was the result?

When was your last pap smear? What was the result?

Any history of an abnormal pap smear?

Are there any toys or devices used during sexual activity? What are your cleaning practices for them?

What caused your delay in seeking care?

Testing

Based on the finding of the patient’s pelvic examination and history of present illness, I would obtain a urine pregnancy, perform a pap smear, and a pelvic ultrasound. I would also test the patient for sexually transmitted infections (STIs) including HIV, Trichomonas, oral and vaginal Gonorrhea, and Chlamydia. Additionally, I would recommend a Bacterial Vaginosis swab, yeast infection testing, testing for mononucleosis, streptococcus, and a complete blood cell count (CBC).

The patient is sexually active but is not on birth control. I would obtain a urine pregnancy test to rule out pregnancy. To rule out that the patient’s cervical bleeding is not related to the development of cervical cancers or human papillomavirus (HPV), I would perform a pap smear. This test looks for abnormal cells on the cervix that could lead to cancer (Penn & Berenson, 2019). I would order a pelvic ultrasound to evaluate the patient’s ovaries, cervix, fallopian tubes, uterus, and bladder. Additionally, I would order a transvaginal ultrasound to check the patient’s uterine walls and assess for polyps or fibroids that could be causing the bleeding (Xu & Xie, 2022).

The patient’s examination yielded a friable cervix, cervical petechia, and some yellow-in-color discharge. I would perform full panel STI testing to ensure she does not have a sexually transmitted disease causing her symptoms. According to Chlamydia, Gonorrhea, and Syphilis (2023), patients with an STI can present with abnormal vaginal bleeding, discharge, and or a friable cervix. I would also collect oral swabs on the patient to check for oral Gonorrhea and Chlamydia due to her complaint of a sore throat and bilateral anterior cervical adenopathy assessed on the exam. For her complaint of sore throat, I would also want to rule out mononucleosis and strep. Additionally, it is necessary to rule out the BV and yeast as the cause of the patient’s vaginal discharge therefore swabs would be obtained. The patient reports bleeding post-colloidal bleeding for six weeks. However, we do not know how frequently she engages in intercourse or how much bleeding she is experiencing; for this reason, I would also order a CBC to check her blood counts.

References

Chlamydia, Gonorrhea, and Syphilis. (2023). Www.acog.org. https://www.acog.org/womens-health/faqs/chlamydia-gonorrhea-and-syphilis

Penn, D., & Berenson, A. (2019, January 31). Pap and HPV tests | Womenshealth.gov. Womenshealth.gov. https://www.womenshealth.gov/a-z-topics/pap-hpv-tests

Mau, K., & Lewis, N. (2022). Evaluating Vaginal Discharge: Distinguishing Normal Physiological Discharge, Vaginitis, and Cervicitis. The Journal for Nurse Practitioners, 18(9). https://doi.org/10.1016/j.nurpra.2022.07.003

Xu, Y., & Xie, D. (2022). Prediction of Factors Associated with Abnormal Uterine Bleeding by Transvaginal Ultrasound Combined with Bleeding Pattern. Computational and Mathematical Methods in Medicine, 2022(1), 5653250. https://doi.org/10.1155/2022/5653250

Hello,

This is an outstanding and insightful post. Vaginal bleeding after intercourse can be attributed to various causes. Identification of the reasons for this post-coital bleeding is essential in determining the fitting management strategy (Tan et al., 2020). It is crucial for a physician to first dismiss serious causes like cancer by conducting an assessment of the vagina and cervix, biopsy, and Pap smear. If cancer is detected, the patient should be referred to a specialist. Other recommended tests for this patient include a complete blood test to assist in discovering various disorders such as immune system conditions, anemia, blood cancers, or infections that may cause post-coital bleeding (BPACNZ, 2019). Coagulation^† and liver function tests are also recommended if the patient’s health history is indicative of haemostatic disorders or a family history of a coagulation disorder. Thyroid-stimulating hormone (TSH) can also be performed if the patient shows symptoms or signs of thyroid disease. Pelvic ultrasound is also recommended if the bleeding is suspected to be attributed to a structural cause. Pipelle biopsy should also be conducted to rule out malignancy or hyperplasia.

References

BPACNZ. (2019). Investigating and managing abnormal vaginal bleeding: An overview. Investigating and managing abnormal vaginal bleeding: an overview – bpacnz. https://bpac.org.nz/2019/bleeding.aspx

Tan, J. H., Jayasinghe, Y. L., Osinski, M. J., Brotherton, J. M., & Wrede, C. D. H. (2020). Recurrent post‐coital bleeding: Should colposcopy still be mandatory? Australian and New Zealand Journal of Obstetrics and Gynaecology, 60(6), 952-958. https://doi.org/10.1111/ajo.13247

Hi Needra, thank you for your post. I agree with your diagnosis of Cervicitis, as she present with signs of inflammation and has risk factors, sexual active, does not practice safe sex. In addition to that I would have diagnosed her with Neisseria Gonorrhea, because gonococci infection is a highly sexual transmuted infection that normally presents with sore throat, fever and general malaise.. (CDC,2021a).

I also agree with your questions .

. Do you practice oral sex

. Do you have oral ulcers now or did you have oral ulcer within the last 3 weeks or more.

Gonococci do cause dysuria, pelvic pain, vaginal discharge or penial discharge, it is also accompanied by dyspareunia, it can also cause PID, infertility if not treated.

I agree SL, needs to be tested for HIV, RPR for syphilis, Urine for complete STI to R/O chlamydia, trichomoniasis and pap smear for HPV and BV.

Sexual transmitted disease like syphilis, trichomonas, chlamydia do presents with similar signs and symptoms, therefore it is vital for providers to preform appropriate test for the correct diagnosis and correct treatment. (Mau, & Lewis. 2022).

Great Post.

Reference

Centers for Disease and Control Prevention. (2023, June 12).Chlamydial Infections. Center for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/chlamydia.htmLinks to an external site. I

Barati, Sedeh, F., et al. (2021). Sex associated Risk Factors for Co-infection with Chlamydia trachomatis and Neisseria, gonorrhea among Patients Presenting to a Sexually Transmitted Infection Clinic. Acta Dermato-Venereologica, 101(1), adv00356.https://doi.org/10.2340/00015555-3721

Thank you for your post. It was very insightful. Iqbal & Willis (2023) discuss that cervicitis can be infectious or non-infectious and that due to the effects of it on fertility, it should be diagnosed and treated promptly. I feel that your testing methods are very thorough. As you noted in your post, it is important to rule out pregnancy since the patient is not on birth control. It is also important to note that the infection could be related to any number of STIs (Ma et al., 2022). By testing for multiple STIs, the provider is able to narrow down the cause of cervicitis, which will improve the discharge education to prevent reoccurrence (Ma et al., 2023). Your additional questions elaborated on the patient’s normal flow during her menstrual cycle, as well as her normal sexual health. These are important factors to consider when determining the cause of the present infection. Discharge education for SL should include safe sex practices, pregnancy prevention, long-term effects of STIs and cervical infection, and routine STI testing (Shuiling & Likis, 2020).

References

Iqbal, U., & Wills, C. (2023). Cervicitis. NIH National Library of Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK562193/

Ma, F., Liu, J., Lv, X., Liu, H., Yang, P., & Ning, Y. (2022). Characterization of allergic inflammation in chronic uterine cervicitis. Clinical and Experimental Immunology, 207(44-52). Doi: https://doi.org/10.1093/cei/uxab026

Links to an external site.

Schuiling, K. D., & Likis, F. E. (2020). Gynecologic Health Care: With an Introduction to Prenatal and Postpartum Care (4th ed.). Jones & Bartlett Learning. https://ereader.chegg.com/books/9781284210378

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