Jennifer

Gayle is a 25-year-old woman who comes to your office for her first Pap smear exam. She tried to have a Pap smear before, but she was unable to tolerate insertion of the speculum. She cannot use tampons during her menses due to pain at her introitus when she tries to insert the tampon. Her last boyfriend broke up with her after 6 months because she was unable to have intercourse with him due to pain at her introitus when trying to insert his penis. The patient cannot remember exactly when this pain started because she didn’t attempt to use tampons until she was 19 years old. She did not attempt intercourse until she was 21 years old. She thinks she noticed this pain the first time she attempted to insert a tampon but cannot be sure. She is extremely anxious and almost in tears about the thought of having a Pap smear, but thinks she “must” have one even though she reports being unable to ever have vaginal intercourse.

Demographic:

 25 year old female

Diagnostic Interview: Other information needed:

– when did you first notice the discomfort?

– when was your first period?-

– any vaginal penetration’s?

– vaginal bleeding?

– vaginal discharge or odor?

– any urinary burning/urgency/frequency?

– any abdominal pain or discomfort?

– depression, substance abuse, and intimate partner screening?
 

Subjective

Chief Complaint (CC): “unable to tolerate any vaginal penetration, it is very painful”

History of Present Illness (HPI): The patient states she is unable to tolerate any vaginal insertion or penetration since the age of 19 years old. It is very painful when attempting to insert a tampon or have vaginal intercourse. This is her 2nd attempt of a pap smear and she is very anxious about the procedure. The first pap smear was unsuccessful due to the pain

and anxiety. Vaginal pain is exacerbated when attempt to insert tampon or have sex. The only relieve is abstinence and not inserting anything into her virginal.

Past Med. Hx (PMH):

Medical history: none

Surgeries/hospitalizations: none

Medications: none

Allergies: NKDA

Immunizations: flu vaccine 10/24, Tetanus 2020, COVID 10/3/21

Health maintenance: physical exam 10/24, dental 11/20,

LMP: 12/14/24

OB/GYN HX: nulliparous

Family Hx:

father: unknown

mother: unknown

Social Hx: Patient is a full-time college student and works part-time target. She states she is heterosexual and states she has never had vaginal intercourse due to discomfort. She started her menses at 13 years old. She exercises daily and eats a well-balanced diet. She denies use of tobacco and illicit drug; however, drinks wine occasionally with family and friends.

Review of Systems (ROS)

Constitutional: Denies any night sweats, insomnia, fever, constipation, or diarrhea. She denies unwanted weight gain or loss. She is alert and oriented, cooperative and answers questions willingly. She makes good eye contact, appropriately dresses with good hygiene. She is sitting on exam table quietly and appears anxious.

HEENT: denies signs and symptoms

Lungs: denies signs and symptoms

Heart: denies any signs and symptoms

Abdominal: denies any signs and symptoms

GU: complaints of painful, burning/frequency/urgency with urination, no problem emptying bladder

M/S: denies any signs/symptoms

NEURO: denies numbness, tingling, weakness

GYN: vaginal pain with intercourse or vaginal insertion

Skin: denies

Objective

BMI: 25.17, VS: 122/68, 72, 16, 98.6, 100% RA WT 135LBS INCH HT 64 IN

HEENT: No head abnormality, PERRL, TM normal bilaterally, nares patent bilaterally, no sinus pain/pressure, oropharynx WNL, no exudate, tonsils 1+, no headaches, nosebleeds, no vision changes

Neck: supple, normal ROM, thyroid WNL, no masses noted

Lungs: normal respiratory efforts, even and unlabored, CTAB, no cough, no SOB or fatigue

Heart: NSR, S1/S2 present, no murmurs, no edema, no chest pain

Abdomen: soft, non-distended, non-tender, normal BS x 4, negative masses, hernia, rebound tenderness or guarding.

GU: positive hematuria, clear yellow urine, no foul odor, negative for abd bacterial, pH 5.2, no glucose, nitrates, ketones, protein, or bilirubin detected in urine

M/S: no deformities or bone/muscular pain

GYN: unable to examine

Integumentary: warm, dry, and intact. no rashes or abnormalities

Assessment (Diagnosis/ICD10 Code):

Diagnosis: Vaginismus. ICD-10-CM: N94.2

Pertinent positives: Discomfort or pain during vaginal penetration, inability to have sex, painful intercourse

Differential diagnosis:

Anxiety, unspecified. ICD-10-CM: F41.9

Pertinent positives: feeling wound up, on edge and nervous

Valvar vestibulitis (provoked vestibulodynia)  ICD-10-CM: N94.810

Pertinent positives: painful sexual intercourse

Plan (USPSTF GUIDELINES)

· UHCG

· UA

· thorough history

Treatment:

· cognitive behavioral therapy/sex therapy (partner)

· topical lidocaine or botulinum toxin therapy

· pelvic pelvic floor exercise

· vaginal dilator therapy

· GYN consult

Education:  Maintain a strong support system and utilize support groups. Promote quality of life and stay involve with usual activities. Expressive and sharing of fears and thoughts.

References:

McEvoy, M. McElvaney, R. & Glover, R. (2021). Understanding vaginismus: a biopsychosocial perspective. Sexual and Relationship therapy. https: //doi.org/10.1080/14681994.2021.200

Pacik, P. & Geletta, S. (2017). Vaginismus treatment: clinical trials follow up 241 patients. Sexual Medicine, 5(2), 114-123. https://doi.org/10.1016/j.esxm.2017.02.002

Katherine

Ty is a 22-year-old who comes to your office for an annual physical exam. On the intake
paperwork, you noted that the gender box was blank. Ty was female assigned as birth but
identifies as They/Them. The patient selected both the “have sex with females” and the “have
sex with males” box in the sexual history.
Answer the following in complete sentences or in question format as if you are asking the
patient these questions:
1. How will you verify the patient’s name and preferred name?
“Can you confirm the name you’d like me to use for you during this visit?”
2. How will you ask for the patient’s gender?
“How would you describe your gender so I can ensure I’m addressing you appropriately?”
3. How will you ask for the patient’s preferred pronouns?
“What pronouns do you use so I can make sure to address you correctly?”
Write a brief SOAP note regarding this patient. Make sure to include your answers to these
questions in your SOAP note.
Chief Complaint: Annual Physical Exam
1. Subjective:
a. What other relevant questions should you ask regarding the HPI?
“How has your overall health been over the past year?”
“Are there any specific health concerns you’d like to discuss today?”
“Have you experienced any new or persistent symptoms recently?”
“When was your last sexual health screening, including STI tests?”
“Do you consistently use protection during sexual activity?”
“Have you or your partners had any STI diagnoses in the past?”
b. What other medical history questions should you ask?
“Do you have any current or past medical conditions?”
“Are you on any medications, including hormones or supplements?”
c. What other family history questions should you ask?
“Do you have a family history of any medical conditions like diabetes,
hypertension, heart disease, or cancer?”
“Is there a family history of conditions that might affect your reproductive health,
like breast or ovarian cancer?”
d. What other social history questions should you include?
“Do you use any substances like tobacco, alcohol, or recreational drugs?”
“What does your diet and exercise routine look like?”
“What does a typical day look like for you regarding work or school?”
“Do you have access to supportive resources, including mental health care?”
2. Objective:
a. Write a detailed, focused physical assessment of this patient.
General appearance: Well-nourished, alert, no acute distress.
Vital signs: Record BP, HR, RR, temp, and BMI.

HEENT: Inspect for any abnormalities, including lymphadenopathy or oral health
issues.
Cardiovascular: Regular rate and rhythm, no murmurs or abnormal heart sounds.
Respiratory: Clear lung fields bilaterally, no wheezes or crackles.
Abdomen: Soft, non-tender, no masses or hepatosplenomegaly.
GU: If a pelvic exam is consented to, inspect for any abnormalities (e.g., lesions,
discharge).
Extremities: No edema or cyanosis.
Skin: Inspect for any rashes, lesions, or concerning skin findings.
b. Is a pap smear necessary for this patient? Why?
Yes, a Pap smear is necessary if Ty has a cervix and is within the age range for
screening. Ty’s sexual history includes male and female partners, which can
increase the risk of HPV-related cervical changes.
c. Explain what other test(s) you will order and perform and discuss your
rationale for ordering and performing each test.
1. STI Screening: Test for chlamydia, gonorrhea, syphilis, HIV, and HPV
based on sexual history and exposure.
Rationale: Ensure comprehensive sexual health care and prevention.
2. Cervical Cytology (Pap smear): Evaluate for cervical dysplasia.
Rationale: Routine screening for cervical cancer patients with a cervix.
3. Comprehensive Blood Work: CBC, lipid panel, and metabolic panel.
Rationale: Evaluate overall health and identify any underlying conditions.
3. Assessment/ Diagnosis:
a. What is your presumptive diagnosis? Why?
Presumptive Diagnosis: Routine Well Woman Exam (Z01.419)
The patient comes in for a yearly check-up and has no specific issues to discuss.
This appointment is all about preventive care, which includes focusing on the
patient’s overall health and sexual health and making sure they receive the proper
health screenings based on their medical, sexual, and social history. Since no
urgent health concerns exist, the visit aligns with routine preventive care.
b. Any other diagnosis or differential diagnosis you would like to add?
Asymptomatic STI (A64)
Hormonal imbalances (R89.1)
4. Plan:
a. What are some educational considerations should you include in regarding
having a male partner?
Emphasize consistent condom use to prevent STIs and unintended pregnancy.
Discuss HPV vaccination if not already completed.
b. What are some educational considerations should you include in regarding
having a female partner?
Educate on UTI prevention and barrier protection for STI prevention.
c. Are there any treatment or medication would you prescribe and why?

HPV vaccine (if not up-to-date).
Prescribe any needed contraceptives or PrEP if STI risk is significant.
d. Explain treatment/management guidelines, including any possible side effects
and/or considerations for the management of the diagnosis.
Regular follow-ups for STI testing and health screenings.
Address mental health or emotional well-being concerns as needed.
e. What patient education is important to include for this patient? (Consider
including pharmacological, supplements, and non-pharmacological
recommendations and education)
Encourage a healthy lifestyle, including diet, exercise, and stress management.
Educate on recognizing signs of STIs, such as unusual discharge, pain, or sores.
Discuss non-pharmacological options for wellness, like mindfulness or therapy.
f. What is the follow-up plan of care?
Return in one year for the next annual physical unless issues arise sooner.
Follow up in 2-4 weeks if any tests return abnormal results.
Provide resources for LGBTQ+ inclusive care if needed.
References:
Advocate For Youth. (2018, June 10). Sexual Agency: Represent. Advocate For Youth.
https://www.advocatesforyouth.org/wp-
content/uploads/2021/08/3Rs_SexualAgency_Represent_HighSchool_FINAL-1.pdf
Alexander, I.M., Johnson-Mallard, V., Kostas-Polston, E.A., Cappiello, J.D., & Hubbard, H.S.
(2023). Women’s Healthcare in Advanced Practice Nursing (3rd ed.). Springer Publishing LLC.
https://online.vitalsource.com/books/9780826167224
Cleveland Clinic. (2024, May 29). Sexual Dysfunction. Cleveland Clinic.
https://my.clevelandclinic.org/health/diseases/9121-sexual-dysfunction
U.S. Department of Health and Human Services. (2024, September 23). Sex, gender, and
Sexuality. National Institutes of Health. https://www.nih.gov/nih-style-guide/sex-gender-