Name: A.N. Other.

Date: 0/00/00

Time:00.00

America

Age: 00

Sex: MF

SUBJECTIVE

Chief Complaint: 

“I have rashes all over my body.”

History of Present Illness:

Onset:

The rash began a week ago, according to the patient, and it first appeared on his arms and legs.

Location:

The rash is spread across his body, including the trunk, limbs, and face, indicating a widespread presentation.

Duration:

Mr. KG adds that the rash has been persistent and has not improved since it first appeared.

Character:

The patient describes the rash as red, elevated, and very irritating, emphasizing the discomfort and influence on his sleep caused by itching.

Aggravating Factors:

The patient has not identified any unique triggers for the rash. He denies using new skincare products, being exposed to new allergies, or experiencing recent environmental changes.

Relieving Factors:

The major symptom is itching, and Mr. KG denies any related pain. He has seen no blistering, discharge, or scaling.

Timing:

The patient states that the discomfort is most severe at night, disrupting his sleep.

Medications:

The patient is not taking any medication.

Previous Medical History

Allergies:

There are no known allergies.

Medication Intolerances:

There have been no reports.

Chronic Illnesses/Major traumas

The patient has a history of minor eczema as a child but no serious medical conditions or traumas.

Hospitalizations/Surgeries

There have been no recent hospitalizations or surgeries mentioned. There is no history of chronic medical diseases such as Diabetes, tuberculosis, asthma, heart issues, HTN, PUD, Cancer, tuberculosis, thyroid difficulties, or renal disease.

Family History

Mr. KG states that neither his parents nor his siblings have any severe medical or psychiatric disorders. There was no family history of dermatological disorders reported.

Social History

The patient finished high school and is now working as an office administrator. He is married and has two children with his wife. He denies any substance misuse and admits to drinking alcohol on occasion (social drinking). There was no mention of tobacco or marijuana use. The patient’s living environment has been determined to be safe.

Review Of Systems

General

There was no substantial weight change. Itching causes sleep disruption, which causes weariness. Denies the presence of fever, chills, or nocturnal sweats.

Cardiovascular

The patient denies having chest pain or palpitations, and there is no swelling or edema.

Skin

The rash is described as red, elevated, and itchy. There are no blisters, discharge, or scaling reported. Denies any recent changes in moles or lesions. There was no history of trauma or skin injury documented.

.

Respiratory

Denies having a cough, wheezing, or being short of breath. There is no history of coughing up blood. There has been no history of pneumonia or TB.

Eyes

The patient denies any eyesight blurring or alterations. The patient uses distance vision glasses.

Gastrointestinal

Abdominal pain, nausea, vomiting, diarrhea, or constipation are all denied. There has been no history of hepatitis, hemorrhoids, or ulcers. Denies having ever had an eating disorder.

Ears

Ear pain, hearing loss, tinnitus, or ear discharge are all denied.

Genitourinary/Gynecological

There was no mention of urinary urgency, frequency, or burning. Denies any changes in urine color. There has been no history of sexually transmitted infections.

Nose/Mouth/Throat

Denies sinus troubles, swallowing difficulties, nosebleeds, dental issues, hoarseness, or throat pain.

Musculoskeletal

Denies any history of back problems, joint swelling or pain, fractures, or osteoporosis.

Breast

N/A

Neurological

Syncope, seizures, brief paralysis, weakness, paresthesias, or blackouts are all denied by the patient.

Heme/Lymph/Endo

HIV, blood transfusions, nocturnal sweats, swollen glands, excessive thirst, increased hunger, or temperature intolerance are all denied.

Psychiatric

Denies having depression, anxiety, sleeping problems, or suicidal thoughts or attempts. There has been no history of psychiatric diagnoses.

OBJECTIVE

General Appearance

A.N. Other. is a well-dressed, healthy-looking adult male who appears to be at ease and not in immediate danger. He maintains eye contact throughout the interview and speaks clearly.

Skin

The skin examination reveals many erythematous papules and plaques spread over the body, consistent with a generalized rash. Lesions are somewhat elevated, with some displaying a central clearing. There are no vesicles or pustules identified. There are no symptoms of trauma or secondary illness.

Head, eyes, ears, nose, and throat (HEENT)

Normalocephalic, atraumatic head.

Pupils are equal, round, reactive to light, and accommodating (PERRLA), and there is no conjunctival injection or discharge.

Canals are patent, TMs are intact, and there is no discharge.

Nose: Pink nasal mucosa, no septal deviation.

Throat: Clear oropharynx with no erythema or exudate.

Cardiovascular

S1 and S2 heart sounds are present, with a steady beat and no murmurs, rubs, or gallops. Capillary refill is within normal limits, with pulses 2+ throughout.

Respiratory

Auscultation of the lungs revealed no wheezing or crackles.

Gastrointestinal

The abdomen is soft and non-tender, with bowel sounds in all quadrants and no hepatosplenomegaly. There are no signs of peritonitis.

Breast

N/A

Genitourinary

External genitalia were normal, with no lesions.

Musculoskeletal

All extremities had a full range of motion and no joint swelling or deformity.

Neurological

The patient is alert and oriented. Speech is clear. No focal deficits were noted. Gait normal.

Psychiatric

The patient is aware and focused, with fluent speech and no focal impairments. His gait is normal.

Laboratory Examinations

Lab Tests

CBC

Special Tests

Diagnosis

Differential Diagnoses

Scabies: (ICD-10 Code: B86 (Scabies))

Scabies is caused by an infestation of the skin by the Sarcoptes scabies mite, which burrows into the epidermis and lays eggs, triggering an immune response characterized by itching, inflammation, and the development of papules, vesicles, and burrows. The intense itching, particularly at night, is caused by both the immune response and the mite’s physical presence.

Nummular Eczema (ICD-10 Code: L30.0 (Nummular dermatitis))

Nummular, or discoid eczema, is a chronic inflammatory skin disorder. While the exact cause is unknown, it is often associated with dry skin and a compromised skin barrier. Disruptions in the skin barrier allow irritants to penetrate, triggering an immune response that manifests as coin-shaped plaques with a distinctive appearance.

Pityriasis Rosea (ICD-10 Code: L42 (Pityriasis rosea))

Pityriasis rosea is a self-limiting skin condition with a viral etiology, possibly linked to human herpesvirus 6 or 7. The exact pathophysiology is unknown, but it typically begins with a single, larger herald patch, followed by the appearance of smaller lesions in a distinctive distribution on the trunk and extremities. The rash is a manifestation of an immune response to the viral infection.

Diagnosis

1.     Allergic Contact Dermatitis (ICD-10 Code: L23.9 (Allergic contact dermatitis, unspecified cause))

Allergic contact dermatitis is an inflammatory skin condition caused by allergen exposure. The process begins with sensitization, in which the immune system identifies a substance as harmful. Upon subsequent exposure, the allergen triggers a delayed hypersensitivity reaction. T lymphocytes are activated, releasing inflammatory mediators such as histamines, which cause vasodilation, erythema, and increased vascular permeability, resulting in pruritus.

Plan/Therapeutics 

o    Plan:

Further testing

Patch Testing:

Patch testing is critical for identifying specific allergens responsible for ACD (Garg et al., 2021). It involves applying small amounts of potential allergens to the patient’s skin under occlusion. The patches remain in place for 48 to 72 hours, mimicking exposure conditions. Depending on the patient’s history, dermatologists will apply a standard set of allergens and additional substances. Reactions are assessed after patch removal.

Photopatch Testing:

When allergen exposure occurs in conjunction with sunlight, photopatch testing may be warranted to identify photoallergic reactions (Tanahashi et al., 2019). Photopatch testing is similar to patch testing but with an additional exposure to ultraviolet (UV) light on specific patches to mimic sunlight exposure.

Irritant Patch Testing:

Differentiating between allergic and irritant reactions is critical, and irritant patch testing can assist in identifying compounds causing non-allergic irritation (Foti et al., 2021).

Laboratory Tests:

To rule out underlying conditions or assess overall health, laboratory tests such as blood tests may sometimes be recommended (Goolsby & Grubbs, 2018). Blood tests may include a complete blood count (CBC) and erythrocyte sedimentation rate (ESR) to evaluate for systemic involvement.

Medication

Topical Corticosteroid (Clobetasol Propionate 0.05% Cream):

Clobetasol propionate is a potent corticosteroid that helps reduce inflammation, itching, and redness associated with ACD (Vanderah, 2023). The tapering approach minimizes the risk of side effects associated with long-term corticosteroid use. A thin layer is applied to affected areas twice daily in the morning and evening.

Oral Antihistamine (Cetirizine 10 mg):

Cetirizine is a second-generation antihistamine that helps reduce itching (Vanderah, 2023). It is given in the evening to minimize potential sedative effects throughout the day. 10 mg once a day.

Emollient Cream (Eucerin Advanced Repair Cream):

Emollient creams help maintain skin hydration, reducing dryness and preventing future flare-ups (Vanderah, 2023). Eucerin Advanced Repair Cream is fragrance-free, minimizing the risk of additional allergens. It is applied liberally to affected areas as needed throughout the day. The route of application is topically.

Short-Term Oral Steroid (Prednisone 20 mg):

For severe cases of ACD, Prednisone provides rapid systemic anti-inflammatory effects (Vanderah, 2023). A short-term course minimizes the risk of systemic side effects. It is given in the dose of 40 mg once daily for three days, then 20 mg once daily for three days. It should be administered orally in the morning for a six-day course.

Education

 Patient education is critical in the comprehensive management of Allergic Contact Dermatitis (ACD), and a customized education plan for Mr. KG is designed to equip him with the knowledge and skills needed to identify and manage triggers, adhere to treatment regimens, and implement preventive measures.

Understanding ACD:

Provide extensive information regarding ACD, highlighting that it is an immune-mediated response to certain allergens upon skin contact and that symptoms may occur 48 to 72 hours after exposure.

Identification of Allergens:

Educate Mr. KG about common allergens, emphasizing the need to identify and avoid them. Discuss probable allergen sources, such as specific metals, scents, and plants, and provide resources on analyzing product labels for allergen presence.

Patch Testing Results:

Discuss the patch testing results, emphasizing positive reactions and their significance (Mahler et al., 2019). Discuss the allergens found and the need to avoid them to avoid future flare-ups.

Skincare Practices:

Provide recommendations on proper skincare habits, such as using fragrance-free and hypoallergenic products (Goh et al., 2022). Emphasize the significance of moisturization to maintain skin barrier integrity and limit the risk of future episodes.

Topical Medication Application:

Correctly demonstrate how to apply a topical corticosteroid (Clobetasol Propionate 0.05% Cream) (Moustafa et al., 2021). Emphasize the necessity of applying a thin coating solely to affected regions, avoiding normal skin, and thoroughly cleaning hands afterward.

Emollient Use:

Teach Mr. KG how to use an emollient cream (Eucerin Advanced Repair Cream) daily to maintain his skin moisturized, emphasizing the application to all areas prone to dryness, even if he is asymptomatic.

Allergen Avoidance Strategies:

Discuss practical allergen avoidance tactics such as wearing hypoallergenic jewelry, employing alternate perfumes, and exercising caution when exposed to potential triggers in the workplace.

Follow-Up and Monitoring:

Emphasize the significance of regular follow-up dermatologic consultations for continuing monitoring, therapy efficacy assessment, and treatment plan changes as appropriate.

Lifestyle Modifications:

Discuss potential lifestyle changes, such as changes in employment habits or personal care product selection, to reduce the chance of future allergen exposure.

Emergency Action Plan:

Provide guidance on spotting severe symptoms that may necessitate immediate medical assistance, and provide Mr. KG with an emergency action plan that includes contact information for medical professionals and the nearest healthcare institution.

Non-medication treatments

Non-medication treatments and medication are essential for effectively managing Allergic Contact Dermatitis (ACD). This comprehensive plan for Mr. KG emphasizes lifestyle changes and skincare practices aimed at reducing allergen exposure, alleviating symptoms, and preventing future flare-ups.

Allergen Avoidance:

Educate Mr. KG on identifying and avoiding specific allergens identified through patch testing. Provide resources on allergen-free alternatives in personal care products, jewelry, and occupational settings. If occupational exposure is a trigger, collaborate with Mr. KG to explore potential changes in his work environment or practices to minimize allergen contact.

Clothing and Textile Considerations:

To decrease irritation, advise Mr. KG to wear loose-fitting, breathable clothing made of natural fibers, such as cotton, and to wash garments and bed linens using fragrance-free and hypoallergenic detergents.

Skincare Practices:

Encourage Mr. KG to use mild, fragrance-free cleansers during bathing to avoid further irritation (Nassau & Fonacier, 2020). Suggest lukewarm water rather than hot water, which can exacerbate dryness. Stress the importance of regular moisturization with emollient cream (Eucerin Advanced Repair Cream) to maintain skin hydration and reinforce the skin barrier.

Avoidance of Irritants:

Inform Mr. KG to avoid products containing harsh chemicals, strong detergents, or excessive fragrances, as these substances can aggravate skin irritation. Emphasize the importance of not scratching, as it can worsen symptoms and lead to complications such as infection. Wear cotton gloves at night if itching is a concern.

Cool Compresses:

Apply cool compresses to affected regions to relieve irritation and inflammation (Patel & Nixon, 2022). Avoid using hot water or ice directly on the skin.

Stress Management:

Talk about the potential influence of stress on ACD symptoms and encourage stress-reduction practices like mindfulness, meditation, or hobbies to boost general well-being.

Follow-Up Dermatologic Consultations:

Emphasize the significance of regular follow-up dermatologic consultations for continuing monitoring and changes to the treatment and non-medication strategy based on the skin’s response.

Evaluation of patient encounter

Mr. KG’s recent patient encounter exemplifies a meticulous and patient-centered approach to managing his diagnosed Allergic Contact Dermatitis (ACD). The diagnostic process began with an in-depth exploration of his medical history and a thorough physical examination, focusing on the distinctive features of his skin condition (Bickley, 2020). The incorporation of patch testing proved instrumental in pinpointing specific allergens contributing to ACD, a patient-centric approach that

The short-term course of oral prednisone was carefully dosed and scheduled, balancing the need for immediate anti-inflammatory effects with the cautious avoidance of potential side effects associated with prolonged saline administration.

Mr. KG received detailed information on the nature of ACD, specific allergen identification, and practical strategies for allergen avoidance in daily life during the educational component of the encounter. Demonstrations on the correct application of prescribed medications ensured optimal adherence while providing an emergency action plan empowered Mr. KG to take proactive measures in the event of severe symptoms.

Mr. KG was educated on textile considerations, skincare routines, and stress management techniques, acknowledging the potential impact of stress on ACD symptoms. The inclusion of regular follow-up dermatologic consultations underscores the dynamic nature of the care plan, allowing for ongoing monitoring and adjustments based on Mr. KG’s responses.

Student Name: B.B.    

Course:    

Patient Name: M.G.

Date: 00-00-00

Time:

Ethnicity: Filipinos

Age: 00

Sex: Female

SUBJECTIVE

Chief Complaint (CC):

“I have vaginal discharges with itching for 3 weeks now.”

History of Present Illness (HPI):  

B.B. is a 65-year-old Filipino woman with a chief complaint of discharge from the genital area accompanied by long-lasting itching that started 3 weeks ago. She states that she noticed about 3 weeks ago an abnormal vaginal discharge with white color and thick consistency. She also recounts an associated symptom of vaginal discharge and intermittent itching, particularly at night. She says, however, that as days passed, there was no significant improvement in her symptoms. She denies experiencing symptoms such as urinary frequency, dysuria, pelvic pain, or abnormal vaginal bleeding are alien to her. In addition, she has no systemic symptoms, including fever, chills, or discomfort. She notes that no aggravating factors are worsening her symptoms except for the itching, which worsens at night. On the other hand, no alleviating factors relieve her discomfort. Mrs. M.G. took the step of avoiding any form of self-treatment and decided to seek medical help as she was experiencing persistent symptoms.

Medications:

None mentioned.

Allergies:

No known food and   drug allergies

Medication Intolerances:

None mentioned

Past Medical History (PMH)  

There is no history of previous chronic illnesses or significant traumas experienced by the patient. She had a previous diagnosis of appendicitis in June 2017, having complained about strong pain in the umbilicus area and the right abdominal region.

Hospitalizations/Surgeries:

Appendicitis, 1987

Surgery:

Appendectomy, 1990

FAMILY HISTORY

M (Mother):

Died at 84 years old from complications of TB.

MGM (Maternal Grandmother):

Died at the age of 98 from complications of type 2 diabetes.

MGF (Maternal Grandfather):

Died at the age 101 after having complications of myocardial infarction.

F (Father):

Currently alive, aged 93 years, with a history of depression and lung cancer.

PGM (Paternal Grandmother):  

Died at 94 years old due to complications of pneumonia.

PGF (Paternal Grandfather):

Died at 99 years of age due to prostate cancer.

Social History:

The patient is a married woman employed as a teacher. She lives with her husband and two children. Does not smoke or use tobacco. She verbalizes that she does not use any recreational drugs or illicit substances. There is no recent travel history.

Her social support group includes family, friends, and siblings.

Tobacco Use:       

She is a non-smoker.

Alcohol Use:

She is a non-alcoholic.

Illegal Substance:

She does not use any illicit substances. She does not use any recreational drugs.

Marital Status:

Married.

Sexual Activity:

She is sexually active

Gender Identity:

Female

Sexual Orientation:

She is heterosexual

Occupation:

She works as a teacher in a local high school.

Nutrition History:

She has an optimal nutritional status.

Family Support:

Her social support group includes family, friends, and siblings.

LMP:

2004. She has been having a regular menstrual cycle since her first menarche at the age of 13 years.

REVIEW OF SYSTEMS 

General:

Denies fever, chills, and weight loss.

Cardiovascular:

Denies chest pain, palpitations.

Skin:

Denies rash, lesions, or changes in skin color.

Respiratory:

Denies cough, wheezing, and shortness of breath.

Eyes:

Denies vision changes and eye pain.

Gastrointestinal:

Denies abdominal pain, nausea, vomiting, diarrhea.

 Ears:

Denies ear pain, discharge, hearing loss, or tinnitus.

Genitourinary/Gynecological: 

+Vaginal discharges with itching. Denies having a history of urinary infection.  + Increased frequency and urgency.

  Nose/Mouth/Throat:

Denies nasal congestion, sore throat, or difficulty swallowing.

Musculoskeletal:

Denies joint pain and stiffness.

Neurological:

Denies headache, dizziness, numbness or weakness.

Heme/Lymph/Endo:

Denies bleeding disorders and lymphadenopathy.

Psychiatric:

Denies depression and anxiety.

Breast:

Denies breast pain. Denies abnormal nipple discharge.

OBJECTIVE 

62 kg

General Appearance:

The patient appears well-nourished and healthy. Appears to be in no acute distress.

Skin:

Warm and dry; no rashes or lesions noted

HEENT:

The head is normocephalic and atraumatic. There are no abnormalities observed.

Cardiovascular:

Regular rate and rhythm, no murmurs, rubs, or gallops. The S1 and S2 sounds are heard.

Respiratory:

Rhythmic movement of the chest wall during inhalation and exhalation. Clear to auscultation bilaterally, no wheezing or crackles.

Gastrointestinal:

The abdomen appears to be flat in shape. Soft, non-tender, and non-distended. There is a bowel sound in all quadrants. No hepatosplenomegaly or masses were palpated.

Genitourinary/ Gynaecology:

External Genitalia:

The vulva looks pale and dry.

Labia minora is thinner and less elastic.

The clitoris is less sensitive to touch compared to normal.

Vaginal Examination:

The vaginal mucosa appears pale, dry, and thin.

The vaginal walls are weak and friable, with areas of easy bleeding upon contact.

Whitish, thick vaginal discharge was observed in the vagina.

Pale, dry mucosa with no erythema or lesions noted

Vaginal pH Measurement:

The vaginal pH is high (>4.5).

Pelvic Examination:

The uterus is smaller, with reduced mobility.

Ovaries appear normal without any masses or tenderness when palpated.

Urethral Examination:

Urethral meatus looks pale and has a dry surface, and there are the symptoms of inflammation.

Patient reports tenderness upon palpation of the urethra.

Bladder Examination:

Bladder is palpable and non-tender.

Perineal Examination:

Perineal skin tends to get dry and may manifest irritation on it.

The pelvic floor muscles show decreased tone and strength.

Musculoskeletal:

Complete range of motion on all limbs. No deformities or swelling on joints were detected during the examination.

Breast:

No masses or abnormal discharge.

Neurological:

Alert and oriented to time, place, and person. No focal deficits were observed throughout the examination. All the cranial nerves from I to XII are intact and function optimally.

Psychiatric:

The patient is concerned about her vaginal discharge. The patient maintains eye contact throughout the examination. A fully cooperative and easy rapport was established after the examination started.

Lab Tests:

None ordered.

Special Tests:

None ordered.

DIAGNOSIS (minimum required differential and presumptive dx, can do more)

Differential Diagnoses

1. Candidal Vulvovaginitis (B37.3):

Candidal vulvovaginitis, commonly known as a yeast infection, is a fungal disease caused by Candida species, often Candida albicans (De Cássia et al., 2021). It usually exhibits symptoms of vaginal itching, burning, and discharges that are not normal. The discharge, in many cases, is described as being thick, white, and cottage cheese-like in appearance. The subjective data shows that a chief differential diagnosis is yeast infection characterized by 3 weeks of white discharge and itching. The patient reported that discharge color and thickness match the ones observed in candidal vulvovaginitis. Besides that, itching in the vagina can also be a typical sign of this illness (Woelber et al., 2020). By looking at the vaginal mucosa objectively, it may appear erythematous and edematous, which also support the diagnosis. Under the microscope, the discharge is tested for yeast cells and pseudohyphae, which provide definitive evidence for candidal vulvovaginitis.

2. Bacterial Vaginosis (N76.0):

Bacterial vaginosis (BV) is the most frequent vaginal infection that is associated with a disruption in the normal vaginal flora with the consequent overgrowth of anaerobic bacteria, particularly Gardnerella vaginalis (Morrill et al., 2020). This condition is usually characterized by a foul-smelling, thin, greyish-white vaginal discharge, which can have a “fishy” odor. Taking into account only subjective data focused on vaginal discharges but not on odor, the most probable differential diagnosis is bacterial vaginosis. Although the patient did not report an odor associated with the discharge, it is essential to note that bacterial vaginosis might also appear without any odor to the patient in some instances. On objective inspection, vaginal discharge can be identified as white, thick, and grayish, accompanied with an elevated vaginal pH. A “whiff” test using potassium hydroxide may produce a typical fishy smell, letting us confirm the diagnosis of bacterial vaginosis (Swidsinski et al., 2023).

3. Trichomoniasis (A59.0):

Trichomoniasis is a sexually transmitted infection caused by the protozoan parasite Trichomonas vaginalis (Rigo et al., 2022). The features like frothy yellow-green vaginal discharge, itching of the vagina, and dysuria usually characterize it. However, it is possible in some cases to be asymptomatic. Although the subjective data in the SOAP note does not explicitly refer to the typical frothy, yellow-green discharge featured in trichomoniasis, this symptom is consistent with the complaint of vaginal discharges with itching. Not all people will develop the standard symptoms recognized for this condition (Van Der Pol et al., 2021). After precisely observing a microscopic analysis of the discharge from the vagina, the motile trichomonads can be seen, which is the definitive evidence that the trichomoniasis is present. Besides this, nucleic acid amplification tests (NAATs) may be carried out for confirmation when microscopic examination cannot provide the answer.

Presumptive Diagnosis (ICD 10 code

Postmenopausal atrophic vaginitis (N95.2)

Postmenopausal atrophic vaginitis is a condition that leads to inflammation, thinning, and drying of the vaginal walls due to estrogenic deficiency after menopause (Pérez‐López et al., 2021a). This disorder is frequently manifested with a variety of symptoms, which are related to vaginal mucosal changes, such as vaginal dryness, itching, burning, dyspareunia (painful intercourse), and sometimes abnormal vaginal discharge. Generally, symptoms begin after menopause takes effect, and estrogen starts to drop in levels which additionally leads to changes in vaginal epithelium and lubrication as well as higher susceptibility to infections and discomfort (Pérez‐López et al., 2021b). Because of subjective symptoms such as vaginal discharge and itching for the past 3 weeks in a 65-year-old postmenopausal female, there is reason to conclude that postmenopausal atrophic vaginitis is a possible diagnosis (Zheng et al., 2021). The age and menopausal status of the patient are vital risk factors to take into account, as there is a fall in estrogen levels after menopause, and this results in vaginal mucosa changes. The subjective complaints of vaginal itching are coinciding with the common symptoms of postmenopausal atrophic vaginitis, illustrating the core inflammation and irritation of the vaginal mucosa. When an exam was done objectively, there was a finding that a woman had pale, dry, and thin vaginal mucosa, which was consistent with postmenopausal atrophic vaginitis. Vaginal walls might seem like they are very delicate and could easily be subjected to trauma because of the hormonal changes at the tissue level. Furthermore, the pH of the vagina may be changed (> 4.5) as a result of changes in the microenvironment of the vagina, which may aggravate symptoms such as itching and discomfort (Lin et al., 2021). The findings of these objective data support the diagnostic basis of postmenopausal atrophic vaginitis and enhance understanding of the pathophysiology triggering the patient’s symptoms.

Plan/Therapeutics:

Confirmation of Diagnosis:

Conduct a complete physical examination to determine the appearance of vaginal mucosa and the pH level (Tanmahasamut et al., 2020). Perform vaginal swabs for microscopy, culture, and sensitivity to find atrophic changes and to exclude other potential infections.

Hormonal Therapy:

You prescribe topical estrogen therapy, for example, a 0.5 to 2 g of Premarin cream administration intravaginally once a day for 1 to 2 weeks, followed by a maintenance dose of 0.5 g 1 to 3 times a week for several months to years as needed (Vanderah, 2023).

Non-Hormonal Measures:

Encourage the use of non-hormonal vaginal moisturizers and lubricants, which enhance vaginal moisture and decrease intercourse discomfort (Shim et al., 2021). Non-hormonal alternatives, such as Replens vaginal moisturizer, should be applied into the vagina as required for symptom relief, usually every 2 to 3 days or before sex, and may be used continuously for management.

Symptomatic Relief:

Antifungal agents such as clotrimazole cream are prescribed. These antifungal agents are applied intravaginally once daily for 7 to 14 days, and the length of treatment is determined by the severity and response to therapy for the yeast infection (Vanderah, 2023).

Follow-Up and Monitoring:

Make a follow-up appointment in 2 to 4 weeks to monitor the patient’s reaction to the treatment and make further adjustments, if necessary (Seferovic et al., 2020). Look for any improvement, like the amount of discharges, itching, and pain during intercourse.

Patient Education:

Specific components include educating the patient about long-term treatment for atrophic vaginitis (Domoney et al., 2020). Identify probable advantages/disadvantages of HRT and remove any fears or misunderstandings the patient may have.

Referral to Specialist:

If the patient does not respond favorably to conservative therapy or is suspected of gynecology diseases, a gynecologist or urogynecologist should be referred for further workup and treatment (Kawaguchi et al., 2020).

Psychological Support:

Psychosocial support and psychological reassurance should be provided to deal with any emotional distress or concerns sparked by the symptoms and their role in the quality of life. Provide the group with necessary resources for support groups and counseling services if required (Ohta et al., 2023).

Diagnostics:

Patient History and Symptoms Assessment:

Perform a thorough medical history interview, paying special attention to menopausal status, previous gynecological conditions, and current complaints, such as the duration and nature of the vaginal discharge and itching (Neal et al., 2020). Explore whether some aggravating factors or recent changes in the medication plan could be responsible for the symptoms.

Physical Examination:

Conduct a detailed pelvic exam to note the vaginal mucosa’s appearance, including signs of atrophy like pallor, dryness, and thinning (Murina et al., 2023). Examine for any other symptoms like vulvar erythema, edema, or dyspareunia (painful intercourse).

Vaginal pH Measurement:

Get a pH indicator strip or pH meter to measure precisely the acidity of the vaginal secretions (Bumphenkiatikul et al., 2020). Atypical vaginitis after menopause is called atrophic vaginitis, which is marked by an increased pH of the vagina (>4.5), which is due to changes in the vaginal microenvironment caused by low estrogen levels.

Vaginal Swab for Microscopy, Culture, and Sensitivity:

Get a vaginal swab to collect a sample of vaginal discharge for laboratory tests (Baek et al., 2021). Microscopic inspection can expose clue cells (characteristic of bacterial vaginosis), yeast cells, or Trichomonas vaginalis (characteristic of trichomonal infection). Culture and sensitivity testing can be useful in finding specific pathogens and picking up the proper antimicrobial therapy if necessary.

Nucleic Acid Amplification Tests (NAATs):

Conduct NAATs, like PCR testing, looking out for the presence of Trichomonas vaginalis DNA in vaginal mucus samples (Van Gerwen et al., 2022). NAATs have high sensitivity and specificity, which makes them applicable for trichomoniasis diagnoses, especially when microscopic evaluation is inconclusive (Fantasia et al., 2020).

Histological Examination:

A biopsy of the vaginal mucosa is recommended if there are suspicions of malignancy or some other pathological condition (Crean-Tate et al., 2020). Histological examination may be useful to detect the amount of vaginal atrophy and the presence of inflammatory changes.

Laboratory Tests:

Additional laboratory tests are performed when necessary, guided by the clinical suspicion and differential diagnosis. Such examinations might be complete blood count, erythrocyte sedimentation rate, and serum hormone levels (e.g., estradiol, follicle-stimulating hormone) to assess hormone status and rule out some systemic conditions causing vaginal symptoms (De Seta et al., 2021).

Education Provided:

Understanding Postmenopausal Atrophic Vaginitis:

Describe the pathophysiology of postmenopausal atrophic vaginitis focusing on the mechanism that produces vaginal mucosal changes, which is the reducing estrogen levels (De Oliveira et al., 2022). Educate the patient on common symptoms such as vaginal dryness, itching, burning, and dyspareunia. Tell the patient these symptoms are common and treatable (Cash, 2023).

Hormonal Changes and Vaginal Health:

Discuss the effects of menopause on vaginal health, considering the decline in estrogen levels and their impact on vaginal lubrication and tissue integrity (Costa et al., 2021). Emphasize that there are ways to maintain vaginal health through HRT or other treatments to alleviate symptoms and stop complications from happening.

Treatment Options:

Let the patient know about the different treatment options for postmenopausal atrophic vaginitis, like hormonal therapy (such as estrogen creams, tablets, or vaginal rings), as well as non-hormonal options like vaginal moisturizers and lubricants. Talk about the benefits, risks, and possible side effects of different treatment alternatives so the patient can choose wisely (Vanderah, 2023).

Vaginal Hygiene Practices:

Teach the patient how to practice good vaginal hygiene to avoid vaginal problems and irritation. Explain why women should not try to use perfumed soaps, douches, or other harsh products to maintain the vaginal pH because they worsen symptoms (Holdcroft et al., 2023).

Sexual Health and Intercourse:

Discuss concerns about sexual intercourse and intimacy, which include discomfort or pain resulting from vagina dryness and atrophy (Cagnacci et al., 2019). Explain ways to better sexual comfort, including the use of water-based lubricants and sexual activities that avoid friction and discomfort (Fantasia et al., 2020).

The patient is a 28-year-old Hispanic or Latino woman who expresses high anxiety and stress aroused from unprotected intercourse. About 4 months ago, the patient had sexual intercourse with an old classmate, and since his death from complications due to HIV, she has been deeply disturbed. These feelings that came to her amidst the familiar atmosphere of the home were fear, regrets, and severe uncertainty about her health condition. The patient’s anxiety has risen to new heights over the last week, driven by the fear of having been exposed to HIV and the burden of carrying its consequences. Even though the patient presented no distinct symptoms that looked like acute HIV infection, such as fever, sore throat, rash, and swollen lymph nodes, she became more concerned about her health and went to see a doctor. Unable to deal with the high rate of uncertainty, the patient has relied on search engines for information related to HIV transmission, symptoms, and treatment alternatives. Still, she remains concerned about the many unknowns about her health status. Even though the patient hasn’t received any particular treatments for the anxiety, she feels the immediate need for medical help to enquire about HIV testing. This episode has made her emotionally insecure due to possible HIV exposure.

None.

Medication Intolerances: None

Past Medical History (PMH)  

There is no past history of previous chronic illnesses or significant traumas. Hospitalizations/Surgeries:
Tonsilitis 2001

Surgery:

Tonsillectomy 2001

Passed away at 43 years old from complications of pneumonia.

MGM (Maternal Grandmother):

Died at the age of 91 from complications of renal failure.

MGF (Maternal Grandfather):

She died at age 105 after having complications of multiple organ failure.
F (Father):

Father is still alive at the age of 61, with a history of major depressive disorder and prostate cancer.

PGM (Paternal Grandmother):  

She passed away at 97 years old due to cerebral malaria.

PGF (Paternal Grandfather):

He passed away at 101 due to lung cancer.

Illegal Substance:

No use of illicit substances. No recreational drug use.

Marital Status:

Single

Sexual Activity:

Sexually active

Gender Identity:

·       Female

Sexual Orientation:

Heterosexual

Occupation:

Teacher.

Nutrition History:

Optimal nutritional status.

Family Support:

She uses her family and siblings as a support system.

LMP: 29/04/2024. She has a regular menstrual cycle.

65 kg

The head is normocephalic and atraumatic. There are no abnormalities observed.

No lesions, discharge, or abnormalities were observed on the external genitals.

Human Immunodeficiency Virus [HIV] Disease (ICD-10 code: B20)

Human Immunodeficiency Virus (HIV) disease is a chronic viral infection characterized by the progressive destruction of the immune system that results in the fatal condition Acquired Immunodeficiency Syndrome (AIDS) if not adequately treated (Patel et al., 2020). Such a hypothesis can be gained from the patient’s self-report of having acts of unprotected sex with an individual known to be HIV positive. This is a serious risk that, combined with the patient’s high anxiety and dread of acquiring an HIV infection, should prompt more diagnostic testing for HIV infection. Subjectively, the patient’s chief complaint of unprotected intercourse with a person whose infected status is unknown poses a threat of HIV transmission. This patient’s anxiety and anguish after the episode are similar to the mental response of many people who are afraid of HIV. The patient’s perception of the HIV disease severity, as expressed in her feelings about the classmate with HIV-related complications dying, reflects the grimness of the situation. The fact that there are not any particular characteristics of acute HIV infection present, such as fever, rash, or swollen lymph nodes, does not eliminate the possibility of an HIV disease (Liu et al., 2020). Nevertheless, the patient’s case history of having unprotected intercourse with an HIV-infected individual remains the leading risk factor for HIV acquisition. At this stage, though vital signs and physical examination findings may not reveal any HIV-specific abnormalities, baseline assessment and follow-up are crucial. Further diagnostic evaluations can confirm or rule out The proper definitive diagnosis. Such investigation may involve diagnostic laboratory testing such as serological tests (e.g., enzyme immunoassay, Western blot, or rapid HIV antibody test) to determine the presence of HIV antibodies or antigens in an individual’s blood. Besides, HIV RNA testing (viral load) is used to evaluate the amount of HIV in the bloodstream and determine the infection stage (Ulfhammer et al., 2021). Should an individual test positive for HIV, the immediate start of antiretroviral therapy (ART) is critical to stave off viral multiplication and preserve an individual’s immune system. The patient should also get overall medical management. This involves tracking for opportunistic infections, immunizations, and adherence support, which are essential for the patient’s health and quality of life. However, the presumptive diagnosis of HIV disease in this case emphasizes the indispensability of proper assessment, testing, and early intercession while dealing with HIV exposure. Collaborative efforts between health care providers and the patient are vital in overcoming the challenges of properly managing the health condition and the patient’s general health and well-being.

Confirmatory Testing: Do HIV serology tests, including an enzyme immunoassay (EIA) and confirmatory Western blot, to firmly pinpoint the HIV infection. Run an HIV RNA test (viral load) to assess the amount of HIV in the bloodstream and define the stage of infection (Augusto et al., 2020). Evaluate immune function and disease progression by CD4 cell count testing.

Immediate Initiation of Antiretroviral Therapy (ART): Start ART immediately when HIV diagnosis is confirmed to reduce viral load and protect immune function. The patient starts getting Antiretroviral Therapy (ART), which is a combined regimen consisting of Tenofovir disoproxil fumarate (TDF) 300 mg and Emtricitabine (FTC) 200 mg (Truvada) plus Dolutegravir DTG 50 mg (Tivicay). Truvada, a fixed-dose combination pill, will be administered daily orally to the patient with the required TDF and FTC doses (Vanderah, 2023). In addition, Tivicay, an integrase strand transfer inhibitor, will be ingested orally once daily. These drugs block different stages of the HIV replication cycle; their combination provides the synergism for suppressing viral replication and preserving immune functions. Individualize ART regimen for viral load, CD4 count, comorbidities, and drug interactions (Michienzi et al., 2021). Emphasize the role of compliance with ART in reaching and maintaining viral suppression, lowering the probability of drug resistance, and maximizing treatment results.

Monitoring and Follow-up: Arrange for routine check-up sessions to closely examine the drug responses, ensure proper adherence, and check for medication side effects or complications (Abera et al., 2023). Conduct lab tests frequently, including HIV viral load, CD4 count, complete blood count, renal function, and liver function tests, to track disease course and treatment effect. Offer ongoing education and assistance to handle any issues related to HIV management, including medication adherence and lifestyle modifications.

Preventative Measures: Give pre-exposure prophylaxis (PrEP) to individuals with high risk, including sexual partners, to reduce HIV transmission (Huang et al., 2020). Advocate for consistent and accurate condom use as a way to reduce HIV transmission during sexual activities. Discuss harm reduction programs that offer tools like needle exchange where HIV infection through injection drug use is a threat to these groups of people.

Psychosocial Support and Counseling: Lend comprehensive psychosocial support, including counseling, mental health services, and peer support groups, to mitigate the emotional and psychological effects of HIV diagnosis and treatment (Okonji et al., 2020). Refer students toward other services for extra guidance through social workers, housing assistance, and financial schemes.

Routine Healthcare Maintenance: Provide routine preventive care, including vaccination, cervical cancer screening (Pap smear), and sexually transmitted infections (STI) screening to keep overall health and well-being in good condition (Strickler et al., 2020). Carefully observe for and immediately take care of any HIV-related complications or comorbidities, which are infections, cardiovascular disease, and metabolic disorders (Fantasia et al., 2020).

Partner Notification and Testing: Promote partner notification and testing of the identified partners and provide them with the link to HIV treatment and prevention services. Offer advice on how to tell about HIV status to sexual partners and possible contacts and provide communication techniques.

HIV Serology Testing: Enzyme immunoassay (EIA) is the primary screening test to get the HIV antibodies in the patient’s blood. Perform confirmatory testing with Western blot or HIV-1/HIV-2 differentiation assay to verify the presence of HIV antibodies and confirm HIV infection (Guiraud et al., 2023). Inform the patient of the window period when the HIV antibodies could not be detected, and suggest a repeat test if the first results are inconclusive.

HIV RNA Testing (Viral Load): Determine the patient’s HIV viral load using nucleic acid amplification tests (NAATs) to evaluate the volume of HIV in the bloodstream (Hsieh et al., 2022). Examine viral load levels to know the stage of HIV infection, follow the course of the disease, and direct treatment decisions. Begin HIV RNA and serology testing for diagnostic information and treatment planning.

CD4 Cell Count Testing: Work out the patient’s CD4 cell count using a flow cytometer to measure disease severity and the functioning of the immune system. Assess CD4 cell count as a staging factor of HIV progression and determine when the time has arrived to administer antiretroviral therapy (ART) (Lembas et al., 2022). Different clinics will periodically follow the CD4 cell count to observe treatment outcomes, determine immune system resumption, and guide toward a longer HIV management process.

Screening for Opportunistic Infections: Perform laboratory tests, for instance, the polymerase chain reaction (PCR) and antigen detection tests, to rule out common opportunistic infections that are associated with HIV, including tuberculosis (TB), cytomegalovirus (CMV), and hepatitis B and C viruses (Önal & Akalın, 2023). Assess the patient’s medical history and signs and symptoms to screen for opportunistic infections and appropriately diagnose by tailoring the tests according to findings.

STI Screening: Undertake screening for sexually transmitted infections (STIs) that often occur together with HIV, including syphilis, gonorrhea, and chlamydia (Thompson et al., 2020). To quickly and correctly diagnose STI pathogens, molecular testing techniques, such as nucleic acid amplification tests (NAATs) or enzyme-linked immunosorbent assays (ELISAs), must be applied. Offer counseling, training, and treatment for STIs to stop transmission, treat concurrent infections, and promote good sexual health.

Baseline Laboratory Testing: Perform comprehensive laboratory tests consisting of complete blood count (CBC), renal function tests, liver function tests, lipid profile, and sugar levels to determine the initial health status and to detect any underlying diseases (Khemla et al., 2023). Assess metabolic parameters and organ function to guide treatment choices, detect possible adverse effects of antiretroviral drugs, and improve general healthcare management.

Transmission and Prevention: Discuss the modes of HIV transmission, including sexual intercourse, sharing needles, and mother-to-child transmission during childbirth or breastfeeding (Myburgh et al., 2020). Emphasize the importance of safer sex practices such as using condoms consistently and correctly, reducing the number of sexual partners, and doing away with high-risk behaviors (Fantasia et al., 2020). Guide on drug harm reduction, including needle exchange programs for individuals who inject drugs, to prevent the spread of HIV.

Medication Adherence: Explain to the patient the importance of adherence to antiretroviral therapy (ART) in achieving viral suppression, preserving immune function, and slowing disease progression (Christopoulos et al., 2022). Talk about taking medication as directed, following the dosage schedules, and avoiding missing doses to increase the treatment effectiveness and reduce the risk of drug resistance. Provide real-life procedures to help with medication adherence, like setting reminders, organizing pillboxes, and incorporating medication-taking into day-to-day activities (Cash, 2023).

Routine Monitoring and Follow-up: Illustrate the importance of scheduling subsequent appointments with healthcare professionals to track the treatment response, medication adherence, and side effects or drug complications (O’Connell et al., 2022). Evaluate the role of laboratory tests, for example, HIV viral load, CD4 cell count, and so on, in monitoring disease progression, treatment decisions, and health background management. Bring up the subject of how the frequency and timing of the follow-up visits can be addressed and the role continuous monitoring plays in general health and wellness (Cash, 2023).

Management of Opportunistic Infections: Supply information about opportunistic infections that occur with HIV, such as symptoms, risk factors, and preventive measures (Schuiling & Likis, 2020). Educate the patient on the necessity of early identification and quick treatment of opportunistic infections to avert complications and enhance results (Siripurapu & Ota, 2023). Equip the patients with self-care skills like hygiene, food safety, and pathogen avoidance to reduce opportunistic infections.

Psychosocial Support and Coping Strategies: Counsel the psychological and emotional effects of the diagnosis and treatment of HIV, which include feelings of fear, anxiety, stigma, and discrimination (Ziersch et al., 2021). Create links to counseling, support groups, peer networks, and mental health services to help the patient overcome emotional stress and adjust to the challenges of living with HIV. Provide advice on stress management methods, relaxation techniques, mindfulness, and other coping skills to foster resiliency and boost emotional well-being.

Student Name:      

Course:

Patient Name: K.J.

Date: 01-01-1976

Time:

Ethnicity: Black or African American

Age: 19

Sex: Male

SUBJECTIVE (must complete this section)

Chief Complaint (CC):

“I am 26 weeks pregnant. I have greyish yellow with an unpleasant smell.”

History of Present Illness (HPI): 

Mrs. K.J. is a 22-year-old Black/African American woman who is 26 weeks pregnant. She came to the clinic with the main problem of foul-smelling vaginal discharge. About a week ago, she noticed these symptoms, which have persisted. This discharge is greyish-yellow and has a foul smell for the patient. The vaginal discharge is accompanied by some itching and mild to moderate burning sensation in the vaginal area. The symptoms have been persistent without any noticeable changes in intensity or timing in the past week. Despite attempts at alleviation, including hygiene measures, the symptoms have remained persistent. There is no aggravating factor mentioned, and the symptoms are located in the vaginal area without radiation to other parts of the body. Besides vaginal symptoms, the patient denies dysuria, abdominal pain, fever, or chills. Generally, the patient experiences the symptoms as less bothersome than unsettling. The discharge is quite uncomfortable during the day compared to the night as she is doing her activities.

Medications:

Prenatal vitamins, one tablet, once daily before a meal, to enhance the absorption of nutrients.

Allergies:

No known food and   drug allergies (NKFDA)

Medication Intolerances:

None

Past Medical History (PMH)

There is no past history of previous chronic illnesses or significant traumas.

Hospitalizations/Surgeries:

There is one previous history of   hospitalization as a result of appendicitis in June 2016.

Surgery:  

Appendicectomy in 2016.

FAMILY HISTORY

M (Mother):

Passed away at 42 years old from complications of type 2 diabetes.

MGM (Maternal Grandmother):

Died at the age of 97 from complications of T.B.

MGF (Maternal Grandfather): 

She died at age 99 after having complications of myocardial infarction.

F (Father):

Father is still alive at the age of 59, with a history of bipolar disorder and lung cancer.

PGM (Paternal Grandmother):  

She is 101 years old and has a history of pneumonia.

PGF (Paternal Grandfather):

He passed away at 97 due to prostate cancer

Social History:

The patient is married and resides with her husband. They currently don’t have children.
• Does not smoke or use tobacco. No recreational drug use. No use of illicit drugs.

She adds that she has a supportive husband, friends, and relatives.

Tobacco Use:       

Non-smoker.

Alcohol Use:

Non-drinker.

Illegal Substance:

No use of illicit substances. No recreational drug use.

Marital Status:

Married.

Sexual Activity:

Sexually active

Gender Identity:

·       Female

Sexual Orientation:

Heterosexual or straight.

Occupation:

Unemployed

Nutrition History:

Optimal nutritional status.

Family Support:

She has a husband and very supportive family members.

LMP: 10/17/2023. She had an irregular menstrual cycle.

REVIEW OF SYSTEMS 

General:

Denies fever. Denies chills. + Fatigue due to pregnancy. Denies weight loss.

Cardiovascular:

Denies chest pain. Denies palpitations, r edema.

Skin:

Denies having rashes. Denies having lesions. Denies any changes in skin texture.

Respiratory:

Denies experiencing cough, dyspnea, and wheezing.

Eyes:

Denies vision changes. Denies experiencing eye pain.

Gastrointestinal:

Denies vomiting. Denies having diarrhea.  + Stomach bloating. + heart burn

 Ears:

Denies having impaired hearing. Denies having earache.

Genitourinary/Gynecological: 

Denies having dysuria or hematuria. Denies having a history of urinary infection. +Vaginal discharge that is grayish-yellow

  Nose/Mouth/Throat:

Denies dysphagia. Denies nasal congestion. Denies having a sore throat.

Musculoskeletal:

Denies having any joint pain. Denies having any muscle stiffness.

Neurological:

Denies headaches. Denies dizziness. Denies changes in sensation.

Heme/Lymph/Endo:

Denies having swollen glands. Denies having swollen lymph nodes.

Psychiatric:

+Anxiety and concerns due to her presenting characteristics due to being pregnant and having an abnormal vaginal discharge

Breast:

Denies breast pain. Denies abnormal nipple discharge.

OBJECTIVE (Document PERTINENT systems only, Minimum 3)

Weight:

150 lbs

Height:

5 ft 6 in

BMI:

24.2

BP:

131/82 mmHg

Temp:

98.5°F

Pulse:

74 beats per minute

Resp:

76 breaths per minute

General Appearance:

The patient appears well-nourished and healthy and has no apparent physiological distress. She seems concerned about her pregnancy and abnormal vaginal discharge.

Skin:

The skin is warm and dry; there are no rashes or lesions.

HEENT:

N/A

Cardiovascular:

Regular rate and rhythm, no murmurs or gallops. The S1 and S2 sounds are heard.

Respiratory:

There is normal symmetry in the expansion and relaxation of the chest wall. The lungs have clear sounds bilaterally on auscultation. There are clear breath sounds bilaterally. There are no wheezes or rales sounds that could be heard on auscultation.

Gastrointestinal:

The abdomen is flat and symmetrical in shape. The abdomen is soft, without tenderness. All four quadrants of the abdomen have present bowel sounds. No masses can be palpated.

Genitourinary/ Gynaecology:

No abnormal discharge or lesions on the external genitalia were observed.

The uterus is enlarged and irregular in shape upon pelvic examination.

The vulva and perineum are highly inflamed and red due to the discharge irritation and itching.

Using a speculum for examination, abnormal greyish-yellow frothy vaginal discharge can be observed.

Cervical erythema and friability.

Musculoskeletal:

All joints have a complete range of motion. No deformities or swelling of joints were detected.

Breast:

No masses or abnormal discharge.

Neurological:

– The patient is alert and oriented to time, place, and person. No focal deficits were detected. Cranial nerves II-XII are intact.

Psychiatric:

The patient is anxious and worried about her abnormal vaginal discharge and the state of the pregnancy. Maintains eye contact. Rapport was established with ease. She is very cooperative. Eye contact

Lab Tests:

Wet mount microscopy: The presence of motile trichomonads.

Vaginal pH: Elevated (>4.5)

Special Tests:

Urinalysis-Pending

DIAGNOSIS (minimum required differential and presumptive dx, can do more)

Differential Diagnoses

1. Bacterial Vaginosis (ICD-10 code: (N76.0):

Bacterial vaginosis (B.V.) is a common vaginal infection because of an imbalance of bacteria in the vagina. Vaginal discharge that looks grayish-yellow in color with an unpleasant odor matches B.V. (Alshahrani, 2023). B.V. generally comes with a thin discharge, grey-white, and gives off a peculiar fishy odor, especially after sexual intercourse or menstruation. This foul-smelling discharge comes from the overgrowth of anaerobic bacteria like Gardnerella vaginalis, which messes up the normal vaginal flora. The secretion can cling to the vaginal wall and may stand out more after sexual activity or after having a bath. On microscopic examination following the findings, the features associated with B.V. include the pH of the vagina greater than 4.5 and clue cells (Metgud et al., 2022). Asymptomatic vaginal discharge is one of the main symptoms of B.V., but some patients also experience burning or itching in their vulva. The risk factors for B.V. comprise numerous sexual partners, douching, and previous instances of STIs. Treatment of the infection usually involves using antibiotics, including metronidazole or clindamycin, to return the healthy bacterial flora to normal.

2. Vulvovaginal Candidiasis (Yeast Infection) (ICD-10 code: (B37.3)

Vulvovaginal candidiasis, generally referred to as a yeast infection, is a fungal infection due to Candida species, primarily the Candida albicans (Fantasia & Fontenot, 2020). Although the patient has itching and discharge in her vagina that cause a yeast infection, the missing part of the thick, white discharge, which looks like cottage cheese, makes the diagnosis less likely (Ostrosky‐Zeichner & Sobel, 2023). Nonetheless, the diagnosis of vulvovaginal candidiasis should be considered in the differential diagnosis because it is a common disease and it can cause similar signs. In vulvovaginal candidiasis, the vaginal discharge is usually thick, white, and clumpy, resembling cottage cheese, and at times is accompanied by intense itching and irritation of the vulva and vaginal parts. The complainant may also give a history of dyspareunia (painful coitus) and vulvovaginal edema, which may be evidenced by redness or swelling of vulvovaginal tissues (Shroff & Ryden, 2020). The risk factors for vulvovaginal candidiasis involve, within the past three months, the recent usage of antibiotics, pregnancy, uncontrolled diabetes mellitus, and immunosuppression. The diagnosis is generally clinical, although microscopic examination of the vaginal fluid may reveal budding yeast cells and hyphae. Treatment typically consists of antifungal drugs such as fluconazole, either orally or as a vaginal suppository or cream.

3. Gonorrhea (ICD-10 code: A54.00):

The infection with gonorrhea is caused by the Neisseria gonorrhoeae bacterium, which is transmitted sexually. With the patient’s complaints of vaginal discharge and odor being indicators of gonorrhea, further testing is needed to obtain a definitive diagnosis. Gonorrhea often causes a vaginal discharge that is yellowish or greenish, along with other unpleasant symptoms such as urinating pain, pelvic discomfort, and irregular menstrual bleeding (Buder & Lautenschlager, 2022). In some cases, the infection can be asymptomatic, primarily in women. On examination, all the signs of gonorrhea, mucopurulent cervical discharge, cervical friability, and cervical motion tenderness may be seen. In suspected cases of gonorrhea, laboratory tests, usually including nucleic acid amplification tests (NAATs), are essential for diagnosis and are often performed on genital specimens (Lachyan et al., 2023). Other sexually transmitted infections must be diagnosed and treated at the same time because the co-infection is quite frequent. Treatment for gonorrhea usually includes antibiotics such as ceftriaxone or cefixime, which are commonly co-administered with azithromycin to ensure that co-infection with chlamydia is also covered.

Presumptive Diagnosis (ICD 10 code

Trichomoniasis (ICD-10 code: A59.9)

Trichomoniasis is a kind of sexually transmitted infection (STI) that is caused by a protozoan parasite named Trichomonas vaginalis (Dhar, 2020). The patient’s chief complaint of grayish-yellow vaginal discharge with a foul smell is in line with the typical symptoms of trichomoniasis (Martínez‐Hernández et al., 2023). Trichomoniasis is characterized by the presence of a frothy, foul smelling vaginal discharge which may change in color ranging from yellow to greenish-gray (Fantasia & Fontenot, 2020). The liquor is usually expressed as having a “fishy” odor, which can be quite noticeable after sexual intercourse or during menstruation. Furthermore, the patient reveals the existence of other symptoms including itching and burning in the genital region, which are the usual accompaniments of trichomoniasis infection. Upon inspection, it is observed that the vagina has erythema and edema, while external genitalia exhibit erythema with petechiae formation (Rein, 2020). The cervix may appear erythematous (red) with punctate hematomas called “strawberry cervix.” The vaginal pH usually is elevated (>4.5), and wet mount microscopy of vaginal fluid could reveal motile trichomonads, which would be diagnostic for the condition. Further, trichomoniasis has no age restriction, but it is more spread among sexually active women of reproductive age. Trichomoniasis is sexually transmitted; it is mandatory to test and treat sexual partners to avoid reinfection and transmission. Hence, regarding the patient’s symptoms, examination results, and risk factors, the suspected diagnosis of trichomoniasis is highly probable. Nevertheless, confirmatory diagnostic testing, like wet mount microscopy, could be significant in making a definitive diagnosis and treatment plan.

Plan/Therapeutics:

Confirmatory Diagnosis:

Conduct wet mount microscopy of vaginal fluid to confirm further the presence of motile trichomonads, which is one of the significant findings in the diagnosis of trichomoniasis (Rahmani et al., 2021). Give additional diagnostic tests a try if needed, for instance, nucleic acid amplification tests (NAATs) for Trichomonas vaginalis, to confirm the diagnosis with precision.

Consideration of Pregnancy:

Make sure that any therapeutic intervention used during pregnancy does not pose any risk to the fetus and is safe for use (Kissinger et al., 2022). Talk about the possible advantages and the side effects of the treatment with the patient, stressing how important it is to treat trichomoniasis to avoid any complications during pregnancy.

Antibiotic Treatment:

Prescribe metronidazole as the first-line treatment for trichomoniasis. It must be noted that metronidazole can cross the placenta but is not associated with an increased risk of congenital abnormalities when used in the second and third trimesters of pregnancy. Give 500 mg metronidazole orally twice daily for 7 days (Vanderah, 2023). Alternatively, a 2-gram single dose of metronidazole can be given, albeit this higher dose must be used cautiously. Stress the need for finishing the whole antibiotics course so that the infection will be fully removed from the body and it will not come back again.

Partner Treatment:

Encourage the patient to inform her sexual partner(s) about her diagnosis and direct them to medical centers for a trichomoniasis diagnosis and treatment (Kissinger et al., 2021). Educate them about partner treatment to help avoid reinfection and transmission.

Monitoring and Follow-up:

Schedule a re-appointment for the patient to check whether the treatment is effective and symptoms are resolving (Muzny et al., 2023). Keep an eye on any adverse effects during pregnancy, like gut discomfort or allergic reactions, and treat them.

Patient Education:

Educate the patient on trichomoniasis, its transmission routes, and preventive measures (Mabaso & Abbai, 2021). Offer counseling regarding safe sex practices, including regular condom use, to avoid the recurrence of STIs and prevent reinfection with trichomoniasis.

Fetal Monitoring:

Fetal monitoring is used during and after the treatment to check the fetus’s well-being and detect any adverse effects of the fetus or treatment (Grant et al., 2020).

Supportive Care:

Provide relief measures to reduce any discomfort that may arise due to symptoms such as vaginal itching or irritation with the use of gentle cleansing techniques and wearing breathable cotton underwear (Piper, 2021).

Diagnostics:

Clinical Evaluation:

Perform a comprehensive medical history and physical examination, including a pelvic exam, to evaluate for signs of trichomoniasis (Kim et al., 2020). Concretely ask as to whether or not there is vaginal discharge, odor, itching, or burning sensation, which are typical manifestations of trichomoniasis.

Vaginal pH Measurement:

Use pH paper or a pH probe to perform a vaginal pH test to evaluate the acidity or alkalinity of the vaginal environment (Rosenbohm et al., 2020). Vaginal pH is commonly altered (>4.5) in trichomoniasis, which may help reach the diagnosis when combined with other signs.

Wet Mount Microscopy:

Collect a sample of the vaginal fluid using a sterile swab and prepare a wet mount slide by mixing the sample with a drop of saline solution on the glass slide (Herath et al., 2021). Consider the examined wet mount slide under a microscope at low and high magnification for motile trichomonads, a hallmark of trichomoniasis. Detecting mobile organisms, usually described as sudden and repetitive jerks, helps diagnose trichomoniasis.

Nucleic Acid Amplification Tests (NAATs):

NAATs for Trichomonas vaginalis DNA in vaginal fluid samples could be performed (Cardoso et al., 2024). NAATs have the highest sensitivity and specificity among tests for the diagnosis of trichomoniasis, allowing them to be the best choice in cases of doubt or when microscopic diagnostic methods are unavailable.

Culture:

In scenarios where neither wet mount microscopy nor NAATs are accessible or definitive, then obtain a culture of vaginal fluids for Trichomonas vaginalis (Danby et al., 2021). Culture permits the isolation and identification of the parasite, but it may take several days before the test results are available.

Pregnancy Considerations:

Ensure that all pregnancy diagnostic tests and procedures are harmless and do not endanger the fetus (Hamouda et al., 2022). Talk about the possible benefits and risks of testing with the patient, stressing that timely diagnosing and treating trichomoniasis in pregnancy is crucial to avoid complications.

Patient Counseling:

Supply counselling and support to the patient during the diagnostic process, answering all her questions and concerns that may arise (Patibandla et al., 2024). Emphasize that early detection and treatment of trichomoniasis are essential for avoiding the future complications of mother and baby.

Education Provided:

Understanding Trichomoniasis:

Tell the patient that trichomoniasis is the most common sexually transmitted infection (STI) caused by a parasite known as trichomonia vaginalis (Ibáñez‐Escribano & Nogal‐Ruiz, 2024). Explain that trichomoniasis affects the vulva, causing symptoms including a greyish-yellow smelling discharge coming from the vagina, itching, and burning.

Transmission and Prevention:

Educate the patient on the means of spread of trichomoniasis, including unprotected sexual intercourse with an infected partner (Keizur et al., 2019). Emphasize the responsibility of safe sex by always using condoms appropriately and correctly to avoid spreading STIs like trichomoniasis.

Impact on Pregnancy:

Talk about the consequences of trichomoniasis throughout pregnancy, especially preterm birth, low birth weight, and disease transmission to the newborn during delivery (Margarita et al., 2020).

Diagnostic Testing:

Describe different diagnostic tests available for trichomoniasis, including wet mount microscopy, nucleic acid amplification tests (NAATs), and culture (Hsieh et al., 2020). Address the safety and effectiveness of these tests during pregnancy and convince the patient that diagnostic procedures will be carried out in a way that will minimize any risks to the patient and the baby.

Treatment Options:

Provide clear directions on the dosage, frequency, and length of the antibiotic therapy and highlight the necessity of taking a full course of the medication to eliminate the infection successfully (Augostini et al., 2023).

Partner Notification and Treatment:

Ask the patient to tell her sexual partners (male or female) that she has trichomoniasis and advise them to seek medical help. Stress that partner treatment is essential to avoid reinfection and transmission of the infection and protect both partners’ health (Cash, 2023).

Follow-Up and Monitoring:

Talk about the importance of follow-up appointments to monitor treatment progress and confirm the cure of symptoms (Marques-Silva et al., 2021). Encourage the patient to know that the success of her pregnancy will be tracked by healthcare providers so that she and her baby remain healthy throughout the pregnancy (Schuiling & Likis, 2020).

Preventive Measures:

Offer counseling about preventing further trichomoniasis episodes through avoidance of douching, proper genital hygiene, and abstaining from sex until treatment has been completed (Wiliiam et al., 2022).

Student Name: VX         

Course:

Patient Name: V.X.

Date: 00-09-00

Time:

Ethnicity: Mexican

Age: 30

Sex: Male

SUBJECTIVE

Chief Complaint:

” I have pelvic pain associated with abdominal cramps.”

History of Present Illness:

Mrs. M.B. is a 23-year-old African American female who complains of pelvic pain and abdominal cramps. The patient claims that symptoms started three days ago; a constant dull pain in her lower abdomen is the primary symptom, and occasionally, the pain radiates to her lower back. The pain has been growing for a while, starting from its onset and being more severe with movement and physical activity. Despite the use of OTC drugs like ibuprofen 400mg orally three times a day, the patient has experienced no substantial decrease in the pain level. Besides the pelvic pain, she complains of dysuria and an increase in the frequency of urination but denies other symptoms like urgency and hematuria as well as vaginal discharge, abnormal bleeding, fever, nausea, vomiting, or change in bowel habits. She has not had a similar previous symptom, history of sexual activity, pelvic trauma, or IUD use. Her menstrual cycle is regular, and she denies any history of sexually transmitted diseases. The pain has undoubtedly altered her normal functioning, including her work and social interactions. Also, the pain often gets worse when she is going about her daily activities during the day.

Medications:

Ibuprofen 400mg orally thrice a day for pain management.

Allergies:

No known food and   drug allergies (NKFDA)

Medication Intolerances:

No known drug intolerances.

Past Medical History (PMH)  

There is no history of chronic diseases or major trauma.

Hospitalizations/Surgeries:

The patient has had no previous hospitalization or surgical   procedures.

Surgery:

No history of past surgical intervention.

FAMILY HISTORY

M (Mother):

She passed away at 53 years old from chronic kidney disease.

MGM (Maternal Grandmother):

Died at the age of 101 from complications of lung cancer.

MGF (Maternal Grandfather):

She died at age 89 after complications of type 2 diabetes.

F (Father):

Father passed away at the age of 61 due to gastric cancer.

PGM (Paternal Grandmother):  

She is 98 years old and has a history of T.B.

PGF (Paternal Grandfather):

He passed away at 103 due to heart failure.

Social History:

The patient is single and lives alone.
• She works as a receptionist in a law firm.
• Does not smoke or use tobacco.
• The occasional social alcohol intake.

No does not use any recreational drug. No use of illegal substances.

She has supportive friends, family, and relatives.

Tobacco Use:       

Non-smoker.

Alcohol Use:

She drinks 2 beers during weekends, and she is a social drinker.

Illegal Substance:

No recreational drug use. No use of illegal drugs.

Marital Status:

Single.

Sexual Activity:

·       Not sexually active

Gender Identity:

·       Female

Sexual Orientation:

Straight or heterosexual.

Occupation:

Receptionist.

Nutrition History:

Optimal nutritional status.

Family Support:

She has friends, relatives, and family members who are very supportive.

Last Menstrual Period (LMP):

03/14/2024. She had an irregular menstrual cycle.

REVIEW OF SYSTEMS 

General:

Denies fatigue. Denies weight loss.  Denies fever. Denies chills.

Cardiovascular:

Denies palpitations. Denies chest pain. Denies edema.

Skin:

Denies rashes. Denies any changes in skin texture. Denies having lesions.

Respiratory:

Denies experiencing cough. Denies having dyspnea. Denies experiencing wheezing.

Eyes:

Denies experiencing eye pain. Denies vision changes.

Gastrointestinal:

Denies vomiting. Denies having diarrhea.  + Stomach bloating. +Abdominal pain

 Ears:

Denies having impaired hearing. Denies having earache.

Genitourinary/Gynecological: 

Denies heavy menstrual bleeding. + Pelvic pain. + Abdominal cramping. Denies having dysuria or hematuria. Denies having a history of urinary infection.

  Nose/Mouth/Throat:

Denies having nasal congestion. Denies having a sore throat. Denies experiencing dysphagia.

Musculoskeletal:

Denies having backaches. Denies having any joint pain. Denies having any muscle stiffness.

Neurological:

Denies experiencing headaches. Denies experiencing dizziness. Denies changes in sensation.

Heme/Lymph/Endo:

Denies having swollen glands. Denies having swollen lymph nodes.

Psychiatric:

+Anxiety, Denies depression. Denies mood changes.

Breast:

Denies having breast pain. Denies having breast lumps. Denies having abnormal nipple discharge.

OBJECTIVE (Document PERTINENT systems only, Minimum 3)

Weight:

59kg

Height:

159 cm

BMI:

23.3

Blood Pressure:

126/87 mmHg

Pulse:

78 beats per minute

Respitatory:

17 breaths per minute

General Appearance:

The patient appears well-nourished and appears uncomfortable due to pain. She is well-oriented to time, place, and person.

Skin:

The skin is warm and dry; there are no rashes or lesions.

HEENT:

The head is normocephalic and atraumatic. There are no ear discharges. The pupils are equal in size, round, and fully sensitive to light and external stimuli. There are no abnormalities observed in the ear or the eyes.

Cardiovascular:

There is a regular rate and rhythm. There are no murmurs or gallops that are heard. The S1 and S2 sounds are heard on the apex and base of the heart, respectively.

Respiratory:

There is symmetry in the expansion and contraction of the heart with each breath. The lungs are clear to auscultation bilaterally. Clear breath sounds bilaterally, and no wheezes or rales sounds were heard upon auscultation.

Gastrointestinal:

The abdomen is flat and symmetrically in shape. The abdomen is soft, without tenderness, and no masses are palpated. Bowel sounds can be heard from all four quadrants of the abdomen.

Genitourinary/ Gynaecology:

No abnormal discharge, lesions, ulcers, or growths were found on the external genitalia.

Perineum: No visible signs of trauma or inflammation.
The uterus is enlarged and irregular in shape.

A speculum examination reveals the presence of cervical motion tenderness (CMT),

Bimanual examination reveals tenderness in the uterus and adnexal tenderness.

Musculoskeletal:

All joints have a complete range of motion; no deformities or swelling of joints were noted.

Breast:

There were no masses, skin changes, or abnormal discharge from the nipple.

Neurological:

– The patient is alert and oriented to time, place, and person. The cranial nerves from I-XII are intact. There are no focal deficits observed.

Psychiatric:

The patient is uncomfortable due to the pelvic pain. Maintains eye contact all through the interaction. She is very cooperative. Rapport established with ease.

Lab Tests:

Urinalysis was requested to check for urinary tract infection.

Special Tests:

A pelvic ultrasound is scheduled to examine pelvic organs.

DIAGNOSIS (minimum required differential and presumptive dx, can do more)

Differential Diagnoses

1. Pelvic inflammatory disease (PID) ICD-10 code: N70.93

Pelvic Inflammatory Disease (PID) is an inflammatory condition of the female reproductive organs mainly as a result of ascent infection from the lower genital tract (Yagur et al., 2021). It covers a series of inflammatory diseases involving the uterus, fallopian tubes, ovaries, and pelvic organs. PID is one of the possible diagnoses for the 23-year-old African American female patient who is complaining of pelvic pain and abdominal cramps. The patient is complaining of the chief complaint of pelvic pain associated with abdominal cramps, which are often among the most common symptoms of PID. Pain is characterized as dull and chronic, mainly localized in the lower part of the abdomen, and aggravated by movement. The manifestation of symptoms three days ago points to the short course or protracted nature of PID. Furthermore, the patient’s demographic factors, such as her age and ethnicity, are also relevant, as PID is more prevalent among sexually active young women, especially those of minority groups (Hillier et al., 2021). During physical examination, a healthcare provider may find signs such as abdominal pain in the pelvis, cervical motion tenderness, and tenderness of adnexal structures. These results demonstrate inflammation and infection affecting the pelvic organs. Nevertheless, it needs to be highlighted that the lack of these physical examination findings doesn’t exclude PID diagnosis, as there are patients who do not show any outward symptoms of PID.

2. Ovarian Cyst (ICD-10 code: (N83.20):

Ovarian cysts are a fluid-filled sac that grows on or within the ovaries (Atta et al., 2021). In our patient with pelvic pain and abdominal cramps, a cyst of the ovary can be the prime cause. The stable pain occupying the lower abdomen, as well as occasional radiation to the lower back, could be the symptoms of the ovarian cyst. These cysts can be different in size and may cause discomfort or aches if they grow large enough to press around close structures. The non-availability of painkillers in over-the-counter medication demonstrates that the pain is from a deeper location in the pelvis, like an ovarian cyst. Also, the dysuria and increased urinary frequency reported by the patient could be the symptoms of the cyst squeezing the bladder and causing irritation and problems with urination. Based on objective test results, like touching the lower abdomen and pelvic region, findings of tenderness may verify the existence of an ovarian cyst. Imaging diagnostic methods like pelvic ultrasound will be used to see the ovaries and confirm the diagnosis (Hara et al., 2021). The type of treatment for ovarian cysts may differ due to the size of the cyst, the symptoms that the patient is experiencing, and also her reproductive plans. The minimal cysts that are less symptomatic may disappear on their accord, while the large and symptomatic ones necessitate medical treatment ranging from pain management to surgery.

3. Urinary Tract Infection (UTI) (ICD-10 code: N39.0):

UTI (urinary tract infection) is another differential diagnosis to take into account in our patient’s case, whose symptoms include dysuria, increased frequency of urination, pelvic pain, and abdominal cramps (Holm et al., 2021). UTIs are infections caused by bacteria affecting any part of the urinary tract, such as the bladder (cystitis) and urethra (urethritis). The symptoms of dysuria and increased urinary frequency indicate that the bladder lining is irritated or inflamed, characteristics of cystitis. Nevertheless, both dysuria and increased urinary frequency are typical UTI symptoms that can also relate to ovarian cysts and pelvic inflammatory diseases (PID). Objective findings on physical examination may include suprapubic tenderness upon palpation and indicate bladder irritation (Khastgir, 2022). In this case, the most crucial diagnostic testing would be urinalysis since it would directly determine the presence of a UTI by detecting the presence of bacteria or white blood cells in the urine. The treatment usually involves prescribing antibiotics based on the strain of bacteria causing the infection. It is crucial to promptly diagnose and treat UTI immediately to prevent further complications like pyelonephritis or repeated infections.

Presumptive Diagnosis (ICD 10 code)

Pelvic and perineal pain (R10.2) 

Pelvic and perineal pain involve diverse sets of symptoms, which make it challenging to identify the root causes of the patient’s reported pain, like pelvic pain associated with abdominal cramps (Lamvu et al., 2021). This diagnosis, therefore, indicates the presence of a vague pain which is located in the pelvic and perineal areas after the doctor has had the chance to order further evaluation to establish the cause of the pain. The patient’s primary concern is pelvic pain accompanied by abdominal cramps. The pain is explained as being dull and enduring, with a primary localization in the lower abdomen and sometimes progressing to the lower back. Symptoms started three days ago are typical for an acute or subacute process. Additionally, the patient complains of dysuria and higher urinary frequency, which might suggest a urinary tract infection. During a physical examination, the patient may be sore when pressure is applied to the lower abdomen or pelvic region. Cervical motion tenderness (CMT) and adnexal tenderness may indicate inflamed pelvic organs, including the uterus, fallopian tubes, and ovaries. Since the patient has urinary symptoms, diagnostic tests like urinalysis can be performed to check for urinary tract infection (UTI). Imaging tests such as pelvic ultrasound may also be ordered to examine for structural abnormalities or diseases within the pelvis. The diagnosis of “Pelvic and perineal pain indicates the presence of pelvic pain with localization to the lower part of the abdomen, which includes the perineal area between the anus and genital organs (French, 2022). This diagnosis is very nonspecific; it does not point to the specific cause of the pain; it simply describes patient’s symptoms. Pelvic and perineal pain may be associated with many causes, including gynecological, gastrointestinal, genitourinary, and musculoskeletal.

Plan/Therapeutics:

1. Comprehensive Evaluation:

Start with a comprehensive medical history and physical examination to determine the nature and extent of the symptoms, particularly the location, duration, and description of the pelvic and perineal pain (Markham et al., 2020). Ask about associated symptoms such as dysuria, urinary frequency, vaginal discharge, menstrual irregularities, and gastrointestinal disturbances to help you make a diagnosis.

2. Diagnostic Workup:

Undertake diagnostic tests based on the clinical suspicion, including urinalysis, to exclude urinary tract infection (UTI) as a possible cause of pelvic pain and to assess the presence of hematuria or pyuria (Huber et al., 2021). Think of pelvic ultrasound or transvaginal ultrasound to determine any structural abnormality or pathology in the pelvis, like ovarian cysts, uterine fibroids, or pelvic inflammatory disease (PID).

3. Treatment Modalities:

Based on what will have been established after diagnostic evaluation, implement focused therapeutic interventions to mitigate symptoms and deal with the fundamental problem. Ceftriaxone 500mg, BD, IV for 5 days may be a therapeutic option if PID or UTI is suspected. This therapy targets causative microbial pathogens identified via diagnostic testing (Vanderah, 2023). Besides, pelvic and perineal pain may be managed through NSAIDs such as ibuprofen 400mg orally and TDS for one week as a means of getting some symptomatic relief.

4. Patient Education and Counseling:

Educate the women about the nature of pelvic and perineal pain, possible causes, and treatment options (Parsons et al., 2021). Talk about ways of pain management, including medication compliance, dosage, and potential side effects of prescribed medications. Fantasia et al. (2020) say that educating the patient regarding lifestyle modifications and self-care measures is meant to enhance pelvic health with a focus on activities such as maintaining a healthy diet, staying hydrated, practicing good hygiene, and avoiding potential triggers to pelvic pain.

5. Follow-up and Monitoring:

Schedule follow-up appointments to check on improvement in the symptoms and solution of the problem and to respond to any further concerns or new emerging events (Wan et al., 2020). Conduct serial diagnostic testing or imaging studies to assess the treatment response and identify any persistent or recurrent pathology, which may require additional medical intervention. Encourage open communication between the patient as well as the healthcare provider so that support and collaboration will be ongoing in managing pelvic and perineal pain more effectively.

Diagnostics:

1. Medical History and Physical Examination:

Get a comprehensive medical history, including length, severity, and pelvic and perineal pain, as well as other associated symptoms like urinary problems, discharge, menstrual irregularities, and gastrointestinal disturbances (De & Mogica, 2023). Make a complete physical exam, for instance, abdominal and pelvic palpation, and look for inflammation, tenderness, and palpable masses in the pelvic and perineal regions (Fantasia et al., 2020).

2. Urinalysis:

Collect a sample of the urine and do a urinalysis to check for signs of urinary tract infection (UTI), like the presence of white blood cells, red blood cells, or bacteria in the urine (Vitale & Lockwood, 2020). Assess for hematuria, pyuria, and urinary sediment that may suggest urinary tract pathology (Schuiling & Likis, 2020).

3. Pelvic Ultrasound:

Perform a pelvic ultrasound or a transvaginal ultrasound to image the pelvic organs and assess for structural defects or pathology in the pelvis, such as ovarian cysts, uterine fibroids, or pelvic inflammatory disease (PID). (Bahrami et al., 2019) Look for signs of inflammation, fluid accumulation, or abnormalities of the uterus, ovaries, fallopian tubes, and surrounding pelvic structures.

4. Laboratory Testing:

Besides the above clinical laboratory test, other additional laboratory tests should be based on clinical suspicion like complete blood count to assess for inflammatory and infectious signs such as elevated white blood cell count (Reid, 2023). Test for Sexually Transmitted Infections like Chlamydia trachomatis and Neisseria gonorrhoeae when you suspect PID (Fantasia et al., 2020).

5. Imaging Studies:

For those cases where a pelvic ultrasound result is inconclusive or if you require further testing, consider other imaging modalities like MR (magnetic resonance) or CT (computed tomography) scans to give a detailed view of pelvic anatomy and pathology (Gopireddy et al., 2022). The pelvic exam should evaluate the presence of inflammation, abscess, and structural abnormalities as the possible reasons for perineal and pelvic pain.

6. Diagnostic Laparoscopy:

If the noninvasive diagnostic modalities are inconclusive, diagnostic laparoscopy can be employed to directly visualize the anatomical structures in the pelvis like endometriosis, adhesions, or other intra-abdominal pathology (Yılmaz et al., 2021). Tissue biopsies should be carried out, or samples should be prepared for microscopic examination to figure out diagnosis and treatment (Cash, 2023).

Education Provided:

1. Understanding Pelvic Pain:

Illustrate the term “pelvic pain” as a discomfort or discomfort that is localized to the lower abdomen and pelvis, including the perineum, and the multifactorial etiology and potential causes (Pereira et al., 2022).

2. Etiology and Potential Causes:

Discuss the possible causes of pelvic pain, which can include reproductive conditions such as pelvic inflammatory disease (PID), endometriosis, ovarian cysts, uterine fibroids, as well as digestive disorders, urinary tract infections (UTIs), and musculoskeletal problems (Di Serafino et al., 2022). Give information about the symptoms and features that accompany each potential cause of the problem to help the patient understand the differential diagnosis process (Schuiling & Likis, 2020).

3. Importance of Medical Evaluation:

Emphasize the need to consult a doctor in case of pelvic pain, especially if it is persistent, severe, and interrupting the daily life schedule (Leuenberger et al., 2022). Encourage the patient to talk freely to healthcare providers about her symptoms, worries, and medical history to ensure the correct diagnosis and treatment (Cash, 2023).

4. Diagnostic Procedures:

Describe the diagnostic procedures usually employed to assess pelvic pain, comprising medical history, physical examination, laboratory testing (urinalysis, complete blood count), imaging studies (pelvic ultrasound, MRI), and the invasive procedures if required (diagnostic laparoscopy) (Cox et al., 2023). Examine the role of each diagnostic test as well as what to expect during the procedure to lower anxiety and cooperation.

5. Treatment Options and Management:

Inform patients of the different pelvic pain treatment options, including medical treatments (such as antibiotics and painkillers), lifestyle modifications such as diet change and exercise, and complementary therapies like physical therapy and acupuncture (Peña et al., 2021). Talk about the risks and advantages of each treatment type and the significance of sticking to treatment schedules and follow-up appointments (Cash, 2023).

6. Coping Strategies and Self-Care:

Provide coping strategies for pelvic pain, including relaxation techniques, stress management, and mindfulness practices (Bittelbrunn et al., 2022). Explain self-care measures that may help relieve discomfort, for example, applying a hot pad, practicing pelvic floor exercises, and keeping good perineal hygiene.

7. Importance of Follow-Up and Advocacy:

Emphasize the significance of periodic follow-up visits with healthcare providers for the monitoring of treatment reactions, the examination for any complications, and the modification of treatment as needed (Singh et al., 2022). Encourage the patient to advocate for herself, seek medical attention if symptoms persist or worsen in spite of treatment, and seek emotional support from friends, family, or support groups if needed.

Student Name: H.H.     

Course:

Patient Name: H.H.

Date: 00-00-20

Time:

Ethnicity: Mexican

Age: 0

Sex: Female

SUBJECTIVE (must complete this section)

Chief Complaint (CC):

” I’m referred by my doctor to see a specialist because I have been having miscarriages, and I have uterine fibroids.”

History of Present Illness:

Mrs. JD, a 50-year-old African American female, came to the clinic for the treatment of her recurrent miscarriages and uterine fibroids and was referred by her primary care physician. In 2019, Mrs. J.D. had her first miscarriage, which was to be followed by several others in the course of the following five years. These miscarriages were followed by frequent episodes of heavy menstrual bleeding and pelvic pains, where Mrs. J.D. localized the pain in her lower abdomen. She describes it as a constant dull, sometimes stabbing sensation accompanied by shooting pain radiating in the lower back and hips during menstruation. As a result of such continuous heavy menstrual bleeding, I need to change sanitary pads very frequently. Also, the pelvic pain, rated 7 out of 10 in terms of intensity, is described as crampy and debilitating. Concerning Mrs. J.D’s pain, it becomes severe during menstruation, physical activity, prolonged standing, stress, defecating, and engaging in sexual intercourse. Although an occasional ibuprofen of 400 mg orally three times a day and a heating pad resolve symptoms partially, the situation has gradually worsened in severity and frequency over the past five years, triggering anxiety and mental distress. Ultimately, Mrs. J.D.’s numerous miscarriages and uterine fibroids had a multi-dimensional effect on her both physically and psychologically.

Medications:

Ibuprofen 400 mg orally three times a day for pain management.

Allergies:

No known food and   drug allergies

Medication Intolerances:

None reported

Past Medical History (PMH)  

There is no past history of previous chronic illnesses or significant traumas that the patient has experienced.

Hospitalizations/Surgeries:

There is no previous history of hospitalizations or surgeries done on the patient.

Surgery:

No history of surgery.

FAMILY HISTORY (must complete this section)

M (Mother):

She passed away at 67 years old from TB.

MGM (Maternal Grandmother):

Died at the age of 97 from complications of type 2 diabetes.

MGF (Maternal Grandfather):

She died at age 99 after having complications of heart failure.

F (Father):

Father is still alive at the age of 79, with a history of bipolar disorder.

PGM (Paternal Grandmother):  

She is 99 years old and has a history of type 2 diabetes.

PGF (Paternal Grandfather):

He passed away at 92 due to myocardial infarction.

Social History:

The patient is married and lives with her husband and two grown-up children.
• She teaches at a local high school.
• Does not smoke or use tobacco. No recreational drug use. No use of illicit drugs.
• The occasional social alcohol intake.She adds that she has a supportive husband, children, family, and relatives.

Tobacco Use:       

Non-smoker.

Alcohol Use:

She drinks 4 beers occasionally during social gatherings.

Illegal Substance:

No use of illicit substances. No recreational drug use.

Marital Status:

Married.

Sexual Activity:

·       Not sexually active

Gender Identity:

·       Female

Sexual Orientation:

Heterosexual or straight.

Occupation:

Teacher.

Nutrition History:

Optimal nutritional status.

Family Support:

She has a husband, 2 children, and family members who are very supportive.

Last Menstrual Period (LMP): 00/00/2024. She had an irregular menstrual cycle.

REVIEW OF SYSTEMS (must complete this section)

General:

Denies fever. Denies chills. Denies experiencing fatigue. Denies weight loss.

Cardiovascular:

Denies chest pain, palpitations, or edema.

Skin:

Denies having rashes. Denies having lesions. Denies any changes in skin texture.

Respiratory:

Denies experiencing cough, dyspnea, or wheezing.

Eyes:

Denies vision changes. Denies experiencing eye pain.

Gastrointestinal:

Denies vomiting. Denies having diarrhea.  + Stomach bloating.

 Ears:

Denies having impaired hearing. Denies having earache.

Genitourinary/Gynecological: 

+ Heavy menstrual bleeding.+ Pelvic pain during menstruation. Denies having dysuria or hematuria. Denies having a history of urinary infection.

  Nose/Mouth/Throat:

Denies dysphagia. Denies nasal congestion. Denies having a sore throat.

Musculoskeletal:

+ Backaches, but not severe. Denies having any joint pain. Denies having any muscle stiffness.

Neurological:

Denies headaches. Denies dizziness. Denies changes in sensation.

Heme/Lymph/Endo:

Denies having swollen glands. Denies having swollen lymph nodes.

Psychiatric:

+Anxiety. + Frustrations due to recurrent miscarriages.

Breast:

Denies breast pain. Denies breast lumps. Denies abnormal nipple discharge.

OBJECTIVE (Document PERTINENT systems only, Minimum 3)

Weight:

65 kg

Height:

165 cm

BMI:

23.8

BP:

130/80 mmHg

Temp:

98.7°F

Pulse:

73 beats per minute

Resp:

16 breaths per minute

General Appearance:

The patient appears well-nourished and has no apparent physiological distress. She appears frustrated and seems to be concerned about recurrent miscarriages.

Skin:

The skin is warm and dry; there are no rashes or lesions.

HEENT:

The head is normocephalic and atraumatic. The pupils are equal in size, round, fully sensitive, and reactive to light. No ear discharges. There are no abnormalities observed.

Cardiovascular:

Regular rate and rhythm, no murmurs or gallops. The S1 and S2 sounds are heard.

Respiratory:

There is symmetry in the inhalation and expiration. The lungs are clear to auscultation bilaterally. Clear breath sounds bilaterally, no wheezes or rales.

Gastrointestinal:

The abdomen is flat and symmetrical. The abdomen is soft, without tenderness, and no masses are palpated. All four quadrants of the abdomen have present bowel sounds.

Genitourinary/ Gynaecology:

No abnormal discharge, lesions, ulcers, or growths were found on or around the external genitalia.

Irregularity of the uterus was palpated during the pelvic examination.

The uterus is enlarged and irregular in shape.

Furthermore, a tender or painful response may be noted upon palpation of the pelvic organs.

A speculum examination proves the presence of uterine cervical and vaginal lesions, such as polyps or tumors.

Cervical motion tenderness.

No adnexal masses were palpated.

Musculoskeletal:

All joints have a complete range of motion; no deformities or swelling of joints were detected.

Breast:

No masses, skin changes, or abnormal discharge from the nipple observed.

Neurological:

– The patient is alert and oriented to time, place, and person. Cranial nerves II-XII are intact, and no focal deficits were detected.

Psychiatric:

The patient is anxious and concerned about her recurrent miscarriages. Maintains eye contact. Rapport established with ease. She is very cooperative.

Lab Tests: Complete Blood Count (CBC):

Hemoglobin (Hb):  13g/dL.

Hematocrit (Hct): 39%.

White Blood Cell Count (WBC): 7000 cells/mm³.

Platelet Count: 300,000 cells/mm³.

Special Tests:

Transvaginal ultrasound for additional evaluation of uterine fibroids.

Urinalysis.

TSH.

DIAGNOSIS (minimum required differential and presumptive dx, can do more)

Differential Diagnoses

1. Recurrent Miscarriages (O26.2):

Recurrent miscarriages are the topic, delving deep into the patient’s concern about her previous pregnancy losses. The reasons behind miscarriages may be due to different causes, including general abnormalities, hormonal abnormalities, uterine abnormalities, autoimmune disease, and maternal age (Ali et al., 2020). In this case, profuse menstrual bleeding and pelvic pain with each miscarriage could suggest a pre-existing gynecological condition as one of the pregnancy loss contributing causes. Objective findings like uterine contour irregularity during a pelvic exam and the possibility of uterine fibroids support the thought of considering recurrent miscarriages as a differential diagnosis. Furthermore, the underlying emotional distress and anxiety, as reported by the patient following her pregnancy losses, reflect the profound effect of this condition on her overall health and well-being (Farren et al., 2020).

2. Adenomyosis (N80.0):

Adenomyosis is a condition exhibiting endometrial tissue penetration into the uterine muscle wall. Similar to endometriosis, adenomyosis also appears with the symptoms of dysmenorrhea, pelvic pain, and heavy menstrual bleeding (Zhai et al., 2020). The objective physical sign of an abnormal shape of the uterus on bimanual examination highly suggests the presence of adenomyosis because this disorder commonly involves uterine enlargement and thickening of the uterine wall (Cash, 2023). This condition tends to cause cyclic pelvic pain and menorrhagia, which in turn may worsen during menstruation, as experienced by Mrs. J.D. Imaging techniques like transvaginal ultrasound and MRI find use in identifying adenomyosis by revealing some of its unique features such as uterine enlargement and nonuniformity of the myometrium. Adenomyosis treatment options range from conservative measures, such as hormonal therapy and pain management, to more definite operations, like uterine-sparing surgeries or hysterectomy, according to the symptoms severity and desire for fertility preservation.

3. Endometriosis (N80.9):

Endometriosis is a persistent gynecologic disease, which includes the presence of endometrial like tissue outside the uterus, usually the pelvis organs and peritoneum. The endometriosis symptoms, such as pelvic pain, painful periods, painful sex, and infertility, are similar to those reported by Mrs. J.D. (De Farias Rodrigues et al., 2020). The subjective findings, like pelvic tenderness on examination, as well as uterine fibroids, create the possibility of endometriosis as a differential diagnosis. The heavy menstrual bleeding of the patient may be caused by endometrial implants inside the pelvic cavity (Arafah et al., 2020).

Presumptive Diagnosis (ICD 10 code

Leiomyoma of Uterus Unspecified (D25.9):

Leiomyomas or uterine fibroids are formed from the uterus’ smooth muscle cells and appear as benign tumors. The presumptive diagnosis of uterus leiomyomas matches the patient’s history of several miscarriages, heavy menstrual bleeding and pelvic pain (Shetty et al., 2021). Subjectively, J.D. stated that she has a history of having a heavy period every menstrual cycle which is in accordance with the signs that are associated with uterine fibroids. She reports the pain as severe and solidified to the lower abdomen, which is a usual symptom of fibroids and caused by contraction of the uterus and stretching of its tissues. Subjectively, the bimanual vaginal examination shows a uterus of irregular shape that indicates fibroid(s) within the uterine wall. This is consistent with uterine fibroids, which often displace the uterus and make it palpable on physical examination (Mongan & Wibowo, 2021). Furthermore, her age of 50 years and her ethnicity, which are associated with an increased risk of uterine fibroids, are demographic characteristics of the patient. Furthermore, Mrs. J.D.’s heavy menstrual bleeding could be due to submucosal or intramural fibroids, which might have been formed as a result of abnormal uterine architecture, hence the excessive uterine bleeding.

Plan/Therapeutics:

1. Surgical Options:

If conservative measures typically are unable to take control over the symptoms or if preservation is a priority, then the surgical treatments can be used (Wang et al., 2020). Besides myomectomy (removing fibroids surgically), hysteroscopic resection, uterine embolization, and hysterectomy would be the best option if the fibroids are very large. The surgery will be appropriate when the fibroid’s size, location, and number are small enough, and it can eliminate those of the patients who prioritize their reproductive goals and overall health.

2. Hormonal Evaluation:

Hormonal studies such as measurement of thyroid function (TSH), prolactin levels, and ovarian reserve testing may be included to assess for hormonal imbalance and ovarian function, which can influence fertility and pregnancy results (Dasari et al., 2023). Hormonal level abnormalities may be responsible for repeat pregnancy losses and may necessitate hormonal supplementation or regulation to promote fertility.

3.Medical Management of Uterine Fibroids:

Hormonal medications such as gonadotropin-releasing hormone (GnRH) agonists, selective progesterone receptor modulators (SPRMs), and oral contraceptive pills (OCPs) can be used to manage fibroids’ associated symptoms, including heavy menstrual bleeding and pelvic pain. Individuals may take orally to 400 mg every 6-8 hours as necessary, causing relief of pain, for example, during menstruation or discomfort of pelvic organs. Oral contraceptive pills with ethinyl estradiol and progestin are taken orally once a day for 21 days, followed by 7-day spots prescriptions of hormone-free product, 3 to 6 months to be used for control of fertility and eliminate vaginal bleeding. On the other hand, leuprolide acetate, which is a gonadotropin-releasing hormone agonist, is injected either once a month or every three to six months for a temporary treatment period. The goal of the medication is to trigger temporary menopause and fibroid shrinkage. In like manner, ulipristal acetate, an SPRM of which the dosage is one tablet, 5 mg per day, may be taken for up to three months to reduce fibroids’ size and mitigate symptoms. Often, these medications can shrink fibroids themselves, prevent heavy bleeding or cramps associated with fibroids, or increase the woman’s chances of conceiving a child by preparing the uterus for embryo implantation in a better fashion.

4. Lifestyle Modifications and Supportive Care:

As for counseling, Mrs. J.D. will be instructed on a few lifestyle modifications to reach the highest overall fertility and pregnancy outcomes (Zarshenas et al., 2020).

Diagnostics:

1. Transvaginal Ultrasound:

Transvaginal ultrasound is, in most cases, the primary imaging modality used to determine the size, number, and location of uterine fibroids. With this tool, physicians can form a clear picture of pelvic organs inside the uterine wall and visualize fibroids that tend to grow inside the uterus (Baușic et al., 2022). Other than that, transvaginal ultrasound can help in the identification (of) whether the fibroids are submucosal, intramural, or subserosal and their impact on the uterine cavity and the surrounding tissues. For instance, in the case of Mrs. J.D., a transvaginal ultrasound will be very beneficial for making up for these findings, such as low-lying fibroids and endometrial polyps which are not easily visible with a second Look ultrasound (Deenadayal et al., 2020).

2. Magnetic Resonance Imaging (MRI):

In addition to other imaging techniques, MRI could potentially be employed as a complementary imaging modality to inspect the uterine fibroids further and to evaluate associated pathologies, such as adenomyosis or endometriosis (Verpalen et al., 2020). MRI allows mammoth detailed images of the pelvic structures as well as discriminating the extent of fibroid infiltration provided the ambiguity on the use of ultrasound is there and to justify detailed anatomical mapping. Notwithstanding, MRI depicts these fibroids by size, location, and detailed blood supply vessels to support the clinicians in their treatment planning and determine the most appropriate intervention (surgery or medication) for Mrs. J.D. (Ciarmela et al., 2022).

3. Hysterosalpingography (HSG):

Hysterogracophy is a radiographic modified technique to diagnose tubal patency and uterine cavity abnormalities (Egbe et al., 2020). It consists of the introduction of a radio-opaque contrast medium into the uterine cavity, followed by the execution of an X-ray examination to detect the presence of abnormalities. HSG screening can not only detect the existence of fibroids, polypoid degeneration, or other intrauterine abnormalities but also help to identify submucosal fibroids or uterine polyps, which may impact one’s fertility or cause a miscarriage by interfering with implantation or causing uterine distortion. HSG is essential to evaluating the uterine cavity and whether the fallopian tubes are blocked. Such as the case of Mrs. J.D., the test may identify the root cause of her infertility, which may be a result of fibroids affecting the uterus.

4. Genetic Testing:

When women are faced with recurrent miscarriages, relevant chromosomal abnormalities or involvement of genetic factors in their future pregnancy losses could be checked utilizing genetic testing (Kasak et al., 2023). A karyotype examination, chromosomal microarray test, or specialized genetic panels could be needed in case Mrs. J.D. or her husband is suspected of having a genetic cause.

Education Provided:

Understanding Uterine Fibroids:

Education about uterine fibroids will be provided in detail to Mrs. J.D., including etiology, pathophysiology, and characteristic symptoms (Uimari et al., 2022). She will discover that uterine fibroids are benign growths that arise inside the muscular wall of the uterus and affect many women during their reproductive years. Different fibroids, such as submucosal, intramural, and subserosal, will be explained, and their impact on fertility and pregnancy outcomes will be provided (Freytag et al., 2021). Mrs. J.D. will be informed that fibroids are common and may or may not cause symptoms like heavy menstrual bleeding, pelvic pain, and infertility, which may require medical and sometimes surgical interventions.

Managing Symptoms:

Educating the audience on different approaches to managing uterine fibroids or their symptoms will be offered. Mrs. J.K. will learn about new therapy focused on lifestyle changes like following a healthy diet, habitual exercises, and stress management techniques. Such therapy approaches may become quite helpful in relieving the symptoms and improving overall well-being (H et al., 2021). Women will be provided with information about pharmacological treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal medicines, to deal with symptoms like bleeding menstrual periods and pelvic pain. Other information, such as potential side-effects and dangers of drug use and medication choices and risks associated with drug use, will be explained to Mrs. J.D., and she will be encouraged to communicate with her healthcare provider to examine issues like appropriate treatment based on her situation for a thorough methodology for her problem (Fantasia et al., 2020).

Optimizing Fertility and Pregnancy Outcomes:

Mrs. J.D. will be enlightened on the influence of fibroids uterine on infertility and fetal covariate (Karlsen et al., 2019). She will find out that fibroids could be responsible for fertility challenges and also for the likelihood of early delivery, miscarriage, and Cesarean section. However, just like in any other medical condition, most women with fibroids can conceive and carry a pregnancy to term without any issues (Schuiling & Likis, 2020). The assistance you will be given in the process of preconception counseling and prenatal care, which is of paramount importance for the close monitoring of the pregnancy to detect and manage any potential complications resulting from fibroids, will thus be discussed (Burrows et al., 2022). Mrs. JD will be given suggestions to work closely with her healthcare provider to achieve her reproductive goals and address the symptoms caused by the fibroids. A personal plan that optimizes pregnancy outcome and fertility will be developed through a consultative approach.

Emotional Support and Coping Strategies:

Mrs. J.D. will be given a chance to share her emotional burden through counseling and emotional support to deal with the psychological effect of the disease, which involves feelings of anxiety, frustration, and grief that is related to recurrent miscarriages and infertility (Rehan et al., 2023). The discussion of coping strategies will include some parts on mindfulness techniques, relaxation exercises, and support groups, which will help Mrs. J.D. to courageously stand against the mental scuffle of living with uterine fibroids and experiencing pregnancy loss (Derav et al., 2023). Advanced recommendation consulting with mental health professionals or other supporting services could be facilitated when the need arises to better Mrs. J.D.’s situation and the family members.

Referral to Specialist:

Mrs. J.D. will be referred to a reproductive endocrinologist or gynecologist who specializes in reproductive disorders and infertility for further management and evaluation of her recurrent miscarriages and uterine fibroids (Petrozza et al., 2023). The specialist will perform a thorough assessment comprising a detailed history, physical examination, and extra diagnostic tests to identify the underlying condition for Mrs. J.D.’s pregnancy losses and to take care of her uterine fibroids.

Follow-up and Monitoring:

Mrs. J.D. will be scheduled for regular subsequent visits to assess the treatment responses; if there is symptom improvement, and if needed, she will be on medication adjustment. (Yu et al., 2022). Specifically, doctors from the specialty, general practitioners, and professionals from other medical fields will work together to provide complete and well-integrated assistance for Mrs. J.D.

Student Name: GG    

Course:

Patient Name: D.G.

Date: 00-00-00

Time:

Ethnicity: Hispanic or Latino

Age: 12

Sex: Male

SUBJECTIVE (must complete this section)

Chief Complaint (CC):

” I have discharges on my left breast nipple.”

History of Present Illness (HPI):

The patient, a 55-year-old Hispanic female, reports discharge from the left breast nipple as her chief complaint. About two weeks ago, she noticed a clear discharge from her left nipple from time to time, which has persisted since then. The discharge happens on occasion without any recognizable triggers and is not linked to pain, flushing, swelling, or changes in the size or shape of the breasts. It happens sporadically at any time of the day or night and does not appear to follow any particular pattern. Discharge is the nipple of the left breast, and it does not expand to other areas of the body or breast. The patient does not specify certain conditions that cause more or less discharge. It sets in spontaneously without any distinguishable triggers. Furthermore, the patient mentioned that discharge is experienced periodically during the day and night. No pattern related to timing or frequency was found. The patient reports no recent trauma or injury to the breast area. She worries about the persistence of the symptoms and seeks medical evaluation to identify what is causing this nipple discharge.

Medications:

The patient is not on any medication

Allergies:

No known food and   drug allergies (NKFDA)

Medication Intolerances:

No medication intolerances have been mentioned.

Past Medical History (PMH)  

There is no history of previous chronic illnesses or major traumas.

 Hospitalizations/Surgeries:

There is no history of previous hospitalizations or surgeries.

Surgery:

No history of surgery.

FAMILY HISTORY (must complete this section)

M (Mother):

Passed away at 45 years old from meningitis.

MGM (Maternal Grandmother):

Died at the age of 83 from renal cancer.

MGF (Maternal Grandfather):

She died at age 89 after having complications of T.B.

F (Father):

Father is still alive at the age of 86, with a history of schizophrenia.

PGM (Paternal Grandmother):  

She is 105 years old and has a history of depression.

PGF (Paternal Grandfather):

He passed away at 73 due to pneumonia.

Social History:

D.G. is married and currently lives with her husband. They are blessed with 3 children. She does not smoke. She drinks a small amount of alcohol occasionally during events. She works as a lecturer. She does not use illicit drugs. She adds that she has a supportive husband, friends, family, and relatives.

Tobacco Use:       

Non-smoker.

Alcohol Use:

She drinks 2 beers occasionally during events.

Illegal Substance:

No use of illicit substances and drugs.

Marital Status:

Married.

Sexual Activity:

·       Not sexually active

Gender Identity:

·       Female

Sexual Orientation:

Either straight or heterosexual

Occupation:

Lecturer

Nutrition History:

Optimal nutritional status.

Family Support:

She has parents, a brother, and a husband who are supportive. Additionally, she has two children, a boy and a girl.

Last Menstrual Period (LMP):

00/00/2024. She had an irregular menstrual cycle.

REVIEW OF SYSTEMS (must complete this section)

The patient denies having a fever. Denies experiencing chills. Denies experiencing fatigue.   Denies weight loss.

Denies any chest pain. Denies having palpitations.

Skin:

Denies having any changes in skin texture. Denies having rashes. Denies having lesions.

Respiratory:

Denies experiencing any dry or productive cough. Denies wheezing.

Eyes:

Denies having any vision changes. Denies eye pain.

Gastrointestinal:

Denies having any stomach bloating. Denies experiencing vomiting. Denies having diarrhea.

 Ears:

Denies experiencing any hearing loss. Denies having ear pain.

Genitourinary/Gynecological: 

Denies having dysuria or hematuria. Denies having a history of urinary infection.

  Nose/Mouth/Throat:

The patient denies having nasal congestion. The patient denies having a sore throat.

Musculoskeletal:

The patient denies having any joint pain. Denies having any muscle stiffness. Denies having any joint swelling.

Neurological:

Denies experiencing headaches. Denies experiencing dizziness. Denies having changes in sensation.

Heme/Lymph/Endo:

Denies having enlarged glands. The patient denies having swollen lymph nodes.

Psychiatric:

Denies having anxiety. Denies having depression. Denies experiencing mood changes.

Breast:

Denies experiencing breast pain. Denies having breast lumps. + abnormal nipple discharge on the left breast.

OBJECTIVE (Document PERTINENT systems only, Minimum 3)

Weight:

54 kg

Height:

150 cm

BMI:

24

Blood Pressure:

122/87 mmHg

Temp:

98.1°F

Pulse:

78 beats per minute

Resp:

17 breaths per minute

General Appearance:

The patient. is well-dressed and well-nourished. She does not appear to be in any signs of physiological distress. She seems to be concerned about the discharge on the left nipple.

Skin:

The skin has no rashes or lesions on the skin surface. On assessment, the skin is dry and warm.

HEENT:

The head is normocephalic and atraumatic.

The pupils are equal in size, round, fully sensitive, and reactive to light. There is no conjunctival pallor present in the eyes.

No ear discharges. There is no abnormalities were observed on the external ear.

Cardiovascular:

There is a regular rate and rhythm. The S1 and S2 sounds are heard on auscultation. No murmurs, rubs, and gallops are heard on auscultation.

Respiratory:

There is the equal expansion and contraction of the chest wall during each breath. The patient has clear breath sounds. There is no wheezing heard on auscultation. The lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi were heard.

Gastrointestinal:

The abdomen is flat and symmetrical. All four quadrants of the abdomen have present bowel sounds. On palpation, the abdomen is soft, non-distended, non-tender.

Genitourinary/ Gynaecology:

No abnormal discharge, lesions, ulcers, or growths were found on or around the external genitalia.

Musculoskeletal:

The patient does not have any deformities or joint swelling. There is a full range of motion on all extremities.

Breast:

Inspection:
No gross deviations or asymmetry were observed.
There was no sign of dimpling, puckering, or rash.
No nipple deviations or retractions were observed. A clear discharge came out from the left nipple upon expression.Palpation:

Neither breast has obvious masses, nodules, or tender areas. The breast tissue felt soft and symmetrical on both sides without any palpable abnormality.

Axillary Examination:
No palpable lymph nodes are felt within either axilla.

Nipple Examination:
No abnormalities were observed in the appearance of the nipples.
The left nipple had a clear discharge when compressed, but the right nipple produced no discharge.

Assessment of Skin and Nipple Changes:
No skin changes like redness, swelling, or inflammation were observed.
No unusual changes were noticed in the nipple appearance except for the discharge from the left nipple, which was clear in color.

Neurological:

– The patient is alert and oriented to time, place, and person. All 12 Cranial nerves are intact and functioning optimally. There is optimal muscle strength and tone across all muscle groups.

Psychiatric:

The patient is in a good mood. She is very cooperative. She is worried about nipple discharge on the left breast.

Lab Tests:

A mammogram is requested to examine breast tissue and rule out underlying diseases

Special Tests:

No special tests are yet ordered.

DIAGNOSIS (minimum required differential and presumptive dx, can do more)

Differential Diagnoses

Duct Ectasia (ICD-10 code: N64.89:

Duct ectasia is a condition with dilatation and inflammation of the ducts under the nipple, which can result in nipple discharge (Bhat et al., 2022). In light of the patient’s description, duct ectasia could be considered a differential diagnosis, given the clear and intermittent discharge reported by the patient. Discharge is described as non-bloody, which defines it as a common characteristic of duct ectasia. Moreover, the lack of related symptoms like pain, redness, or swelling indicates that the etiology is duct ectasia and may not be malignant. The clinical indication of liquid discharge from the left nipple, verified by the clinical examination signs, confirms this diagnosis. Ectasia of the duct usually affects premenopausal women, corresponding to the patient’s demographics as a 55-year-old female (Usmani et al., 2020).

Intraductal Papilloma (ICD-10 code: D24.1.)

Intraductal papilloma is a benign breast duct growth that can cause nipple discharge (Li et al., 2020). The manifestation of the patient’s clear, intermittent nipple discharge corresponds with the visualization of intraductal papillomas non-bloody discharge. When the discharge is benign, it could be associated with pain in the nipple or a detected lump in the breast that needs to be checked (Mitchell & Johnson, 2022). An objective physical examination with a typical appearance of clear discharge from the left nipple without palpable masses or other abnormalities aligns with this diagnosis. Intraductal papillomas are more prevalent in women aged 40-50 but may occur at any age; hence, this concern must be considered in this patient (Shen et al., 2020).

Breast Cancer (ICD-10 code: (C50.919):

Due to the mentioned patient’s age, gender, and nipple discharge, breast cancer may be considered a possible diagnosis (Nemer & Kussaibi, 2020). While the discharge described as clear and intermittent by the patient can be a clue to the onset of breast cancer, there are times when bloody discharges are present only in its later stages (Mitchell & Johnson, 2022). Subjective examination results of clear discharge from the left nipple are not an absolute factor for malignancy, as breast cancer can be manifested without any palpable abnormality. Interestingly, the lack of accompanying symptoms, such as pain and breast changes, does not necessarily rule out cancer because some tumors can be asymptomatic or produce such subtle symptoms (Shetty, 2021). Considering the severity of this diagnosis, radiological studies such as mammography and biopsy may be necessary to rule out malignancy further and start immediate care if needed.

Presumptive Diagnosis (ICD 10 code

Physiologic Nipple Discharge (ICD-10 code: (N64.52)

Physiological nipple discharge is a normal and harmless type of nipple discharge that is not associated with any pathology (Gulati et al., 2023). A hormonal imbalance can cause it and is commonly seen in women, particularly during the reproductive years. In the context of the patient’s presentation, physiologic nipple discharge becomes the presumed diagnosis because of the evident nature of the discharge as being clear and intermittent, as reported by the patient. Not being accompanied by the symptoms of pain, redness, or swelling also strengthens our diagnosis, as physiological nipple discharge does not usually cause any accompanying discomfort or breast changes. Findings from objective examination of the left nipple discharge on expression indicate the characteristics that physiologic nipple discharge usually exhibits. The patient describes the discharge as non-bloody, allegedly in line with the physiologic nipple discharge (Alhadethy et al., 2021). Further, the fact that no palpable masses or other abnormalities are found on breast examination is a sign of a non-pathologic etiology, supporting the presumptive diagnosis of physiologic nipple discharge (Mitchell & Johnson, 2022). Besides that, the patient’s demographic background as a 55-year-old woman may seem uncommon for physiological nipple discharge since the latter is usually found in young women. Furthermore, hormonal changes can occur at any time of life, and physiological nipple discharge can appear in women who are no longer of reproductive age.

Plan/Therapeutics:

Patient Education:

Inform the patient that physiologic nipple discharge is a frequent but benign occurrence, mainly in women of reproductive age. Teach the patient about the hormone fluctuations that can cause nipple discharge, which are often benign (Karimova & Slanetz, 2020). Talk about physiologic nipple discharge triggers, such as hormones during menstruation, pregnancy, and lactation.

Reassurance:

Tell the patient that her additional discharge is most likely physiologic, given the absence of associated symptoms such as nipple pain, rash, or swelling. Allay the patients’ fear of nipple discharge being cancerous or related to other dangerous conditions.

Medication administration:

The administration of drugs is seldom necessary for physiologic nipple discharge, which is treated without medication (Stafford et al., 2021). Physiologic nipple discharge is a benign, transient, and hormonal-related phenomenon that is unrelated to any pathology in the vast majority of cases. Nevertheless, just in case the patient experiences nipple discharge associated with discomfort or irritation, ibuprofen 400mg could be prescribed orally TDS for 5 days to provide symptom relief (Vanderah, 2023).

Lifestyle Modifications:

Advised the patient not to overstimulate the nipples, which may worsen nipple discharge (Rosen-Carole & Stuebe, 2022). Motivate the patient to clean the breast area properly and refrain from wearing bras or clothes that may be tight-fitting over the nipples.

Follow-up and Monitoring:

Make an appointment for a follow-up to check on the patient’s symptoms and continue to give them support and reassurance (Spataro & Fitzpatrick, 2020). Talk about the possible changes in the symptoms, such as the beginning of other signs or changes in the discharge’s nature.

Referral to Specialist:

Although physiological nipple discharge often does not require further examination or treatment, a referral to a breast specialist should be done if the patient remains worried or doubts about the nature of the discharge (MacDonald, 2023). A patient can be further reassured by a breast specialist who can perform additional diagnostic workups if the doctor thinks they fit based on the patient’s clinical data and individual risk factors.

Patient Counseling:

Render the patient a chance to ask questions and settle all the confusion surrounding her symptoms (Douglas, 2022). Provide counselling and support to relieve any anxiety or distress related to nipple discharge and assure that the symptom is not associated with severe conditions.

Documentation:

Record the patient encounter in detail by discussing the diagnosis, patient education, and the follow-up and monitoring plan (O’Neil et al. 2021). While documenting the case in the patient’s medical record, ensure that the presumptive diagnosis of physiologic nipple discharge and the details of the discussions or counselling sessions are accurately reflected in the medical record.

Diagnostics:

Clinical History and Physical Examination:

Start with a health history containing information about the beginning, duration, frequency, and nature of nipple discharge (Sanford et al., 2022). Conduct a thorough physical exam, emphasizing the breast and nipple area, and look for abnormalities, palpable masses, or signs of inflammation (Schuiling & Likis, 2020). Evaluate the presence of associated symptoms like breast pain, redness, swelling, or breast texture changes.

Detailed Breast Examination:

Perform a complete self-examination of both breasts, paying special attention to the nipple of the affected breast and adjacent breast tissue (Pleasant, 2022).

Cytological Examination:

Conduct cytological studies of the nipple discharge for cell composition analysis and rule out any atypical or cancerous cells. Nipple discharge can be collected by using a nipple aspirate or manually expelling a few drops of discharge onto a glass slide, which can be examined under a microscope (Zhang et al., 2020). Cytologic sampling enables us to distinguish physiologic nipple discharges from pathologic ones like breast cancer and intraductal papilloma.

Hormonal Evaluation:

Consider hormonal testing, especially in premenopausal women, and check for any hormonal imbalances and fluctuations responsible for nipple discharge (Vavolizza & Dengel, 2022). Hormonal testing includes prolactin, thyroid, and serum reproductive hormones like estrogen and progesterone.

Biopsy:

Perform breast biopsy only when the imaging and cytological analysis are inconclusive and suspicion of underlying pathology exists (Allah & Osama, 2020). Biopsy will be necessary if there are suspicious findings on imaging studies, persistent symptoms, or if nipple discharge is related to palpable masses or other abnormalities.

Education Provided:

Explanation of Physiologic Nipple Discharge:

Describe in detail physiologic nipple discharge, which is a common and usually normal phenomenon among women (Weaver & Stuckey, 2022). Explain that hormonal fluctuations, especially during menstruation, pregnancy, or breastfeeding, maybe a cause of nipple discharge without any underlying pathology.

Normal Variations in Nipple Discharge:

Highlight normal variations in nipple discharge, explaining that it can be clear, milky, or slightly yellow (Jha et al., 2022). Tell patients that physiologic nipple discharge is usually bilateral and may be intermittent, sometimes without symptoms such as pain or changes in the breasts.

Differentiating Physiologic Nipple Discharge from Pathological Causes:

Educate the patient about the difference between physiologic nipple discharge and pathological causes such as breast cancer and intraductal papilloma (Chan et al., 2022). Indicates that physiologic nipple discharge is typically not bloody and is not associated with palpable masses or other breast abnormalities.

Triggers and Aggravating Factors:

Talk about many causes of physiologic nipple discharge, such as hormonal fluctuations during the menstrual cycle or sexual stimulation (Restrepo et al., 2021). Ensure the patient is aware of her symptoms and see if she can identify any specific triggers or factors that worsen the discharge.

Breast Health and Self-Examination:

Teach breast self-examination techniques and ask the patient to conduct a regular self-examination to check for any noticeable changes in the texture, size, or appearance of breasts. (Nasirzadeh & Esmaeilzadeh, 2023) Emphasize the importance of knowing your breast anatomy and notifying your healthcare provider about any new or alarming symptoms.

Lifestyle Modifications:

Suggest lifestyle modifications like having a healthy weight, exercising regularly, and avoiding alcohol binges (Balsarkar, 2022). You can highlight the influence of lifestyle variables, including smoking and stress, on breast health and nipple discharge.

Follow-up and Monitoring:

Describe the plan for follow-up and monitoring, as well as the appointment dates when the physician will see the patient, assess their symptoms, and give the necessary support and reassurance (Sherman & Walsh, 2022). Help her to understand that it is essential to see a doctor immediately if she experiences any changes in symptoms, the appearance of new things, or if she has questions about her breast health (Fantasia et al., 2020).

Addressing Emotional Concerns:

Acknowledge the emotional impact of having nipple discharge and let the patient know that their feelings are valid (Hanalis-Miller et al., 2022). Provide emotional support and reassurance, stressing that nipple discharge is often a physiologic occurrence, not suggesting any severe disease (Cash, 2023).

Student Name: KL

Course:

Patient Name: K.L.

Date: 00-00-00

Time:

Ethnicity: Mexican

Age: 00  

Sex: Male

SUBJECTIVE (must complete this section)

Chief Complain (CC):

“I don’t have sexual desire for over the past years now.”

HPI: 

Onset:

A.B. mentions a gradual decline in the sex drive for the past 2-3 years. At first, she says that she had normal sexual arousal and pleasure during her late adolescence and early twenties. However, she started having a lower sex drive at the age of 22. She found this condition to be triggered by the stress of excelling in her studies and job search. She was able to identify and manage the issues that prompted her to experience decreased libido. Nevertheless, her lower sex drive persisted.

Location:

The main issue is directly associated with A.B.’s mental health, as she is diagnosed with a lack of interest in sexual activities. Physically, no localized symptom or discomfort was reported.

Duration:

The libido deterioration has been present for approximately four years or more, dating back to A.B.’s early twenties. A.B. mentions that a wave of symptoms appeared, which began at a time of increased stress and academic pressure in her college.

Character:

A reduction of interest or lack of arousal is the main feature of the decrease in interest in A.B.’s sexual activities. Her decrease applies to both solitary and partnered sexual endeavors. A.B. mentions the inability to experience an emotional connection with sexual stimuli and the lack of sexual fantasies and spontaneous desire.

Aggravating Factors:

A.B. admits that she has no definite causes or exacerbations that worsen her lack of sexual desire.

Relieving factors:

A.B. explains that the condition prevails across different situations, whether in a relationship or not and does not change in terms of her partner or the sexual setting. Attempts to resolve this problem by means of stress reduction, lifestyle changes, or relationship therapy have proved to be unsuccessful.

Timing:

Her decreasing libido has been gradual, with no periods of push and pull or any remissions. A.B. acknowledges that the problem persists despite periodic cycles, hormonal fluctuations, and environmental stressors.

Medications:

A.B. denies the use of medications that may alter her libido.

Allergies:

NKFDA (No known food and drug allergies) has been recorded.

Medication Intolerances:

No medication intolerances

Past Medical History (PMH)  

A.B. mentioned no chronic illnesses or major traumas. She reports no previous medical history related to sexual dysfunction.

Hospitalizations/Surgeries:

No past hospitalizations or surgeries.

Surgery:

No prior history of surgery.

FAMILY HISTORY (must complete this section)

M (Mother):

A.B.’s mother passed away at 45 years old from myocardial infarction.

MGM (Maternal Grandmother):

A.B.’s maternal grandmother died at the age of 83 from type 2 diabetes complications.

MGF (Maternal Grandfather):

A.B.’s Maternal Grandfather died at age 89 after having complications with gastric cancer.

F (Father):

Father is still alive at the age of 56, with a history of kidney stones. He also has a history of depression.

PGM (Paternal Grandmother):

A.B.’s paternal grandmother is 91 years old and has a history of hypertension.

PGF (Paternal Grandfather):

A.B.’s paternal grandfather passed away at 73 due to lung cancer.

Social History:

A.B. is currently married and lives with her husband. They do not have any children. She does not smoke. She drinks alcohol occasionally during events and celebrations. She works as a marketing executive. Denies using illicit drugs. She shares that she has a supportive social circle of friends and relatives.

Tobacco Use:       

Non-smoker.

Alcohol Use:

She drinks two beers occasionally.

Illegal Substance:

No use of illicit drugs and substances.

Marital Status:

Married.

Sexual Activity:

·       Not sexually active

Gender Identity:

·       Female

Sexual Orientation:

Either heterosexual or straight

Occupation:

Marketing executive.

Nutrition History:

Optimal nutritional status.

Family Support:

A.B. has a sister and a husband who are very supportive. She has no children. A.B. has a very supportive social circle that includes her husband, relatives and friends.

Last Menstrual Period (LMP):

00/00/2024. A.B. Mentions that she had irregular menses previously.

REVIEW OF SYSTEMS (must complete this section)

General:

A.B. denies having a fever. Denies fatigue. She also denies experiencing chills. + moderate weight loss.

Cardiovascular:

A.B. Denies palpitations. Denies chest pain.

Skin:

Denies any changes in skin texture. Denies rashes. Denies having any lesions.

Respiratory:

A.B. denies experiencing wheezing. Denies having any cough. Denies dyspnea.

Eyes:

A.B. denies having any eye pain. Denies having vision changes.

Gastrointestinal:

Denies having nausea. Denies having vomiting and diarrhea.  Denies having Abdominal/pelvic pain. Denies having any stomach bloating.

 Ears:

A.B. denies experiencing ear pain. Denies hearing loss.

Genitourinary/Gynecological: 

Denies having any urinary infection. Denies dysuria or hematuria. + dysmenorrhea. + Loss of sexual desire

  Nose/Mouth/Throat:

Denies having a sore throat. Denies nasal congestion.

Musculoskeletal:

A.B. denies experiencing muscle stiffness. Denies swelling. Denies experiencing joint pain.

Neurological:

A.B. denies experiencing any dizziness. Denies experiencing headaches.

Heme/Lymph/Endo:

A.B. denies having any bleeding disorder. Denies having enlarged glands or lymph nodes.

Psychiatric:

+Anxiety, depression. Denies mood changes.

Breast:

A.B. denies observing abnormal nipple discharge on her breast.  Denies having breast lumps. Denies having abnormal nipple discharge. Denies breast pain.

OBJECTIVE (Document PERTINENT systems only, Minimum 3)

Weight:

57 kg

Height:

155 cm

BMI:

23.73

BP:

124/75 mmHg

Temp:

98.9°F

Pulse:

73 beats per minute

Resp:

18 breaths per minute

General Appearance:

A.B. is well-dressed and well-nourished. She does not appear to be in any signs of physiological distress. She seems worried and concerned about her decreased sexual desire.

Skin:

Upon inspection, A.B.’s skin has no lesions or rashes on the surface. Her skin is warm and dry.

HEENT:

Upon inspection, A.B.’s head is atraumatic and normocephalic.

The pupils are equal, round, and reactive to light. No scleral icterus or conjunctival pallor.

No ear discharges or abnormalities. The tympanic membrane is shiny grey on inspection.

Cardiovascular:

None of the murmur, gallops, or rubs are heard. There is a regular rate and rhythm.  Both S1 and S2 heard.

Respiratory:

Upon inspection, there is symmetry in the expansion and contraction of A.B.’s chest. No wheezes, rales, or rhonchi were heard. No dyspnea or crackling.  Lungs are clear to auscultation bilaterally. A.B. has clear breath sounds and no wheezing on auscultation.

Gastrointestinal:

On inspection, the abdomen is symmetrical and flat in shape. On palpation, the abdomen is soft, non-tender, and not distended. All four quadrants of the abdomen have present bowel sounds.

Genitourinary/ Gynaecology:

On inspection, no ulcers or abnormalities were observed on the external genitalia. Labia majora: It exhibits bilateral symmetry and colored skin and hair.
Labia minora: The right labia minora is 42.1mm (about 1.6 in) long and 13.4mm (about 1.5in wide, while the left labia minora is 42.97mm (about 1.7in) long and 14.5mm (just over 0.5in) wide.Perineum: Unchanged and free of the visible signs of trauma or inflammation.
The vulva is symmetric in appearance.
No abnormal discharge, lesions, ulcers, or growths were found on or around the external genitalia.

No lesions or discharge were present.

Musculoskeletal:

All extremities had a full range of motion. A.B.  has no deformities or joint swelling were observed.

Neurological:

– A.B. is alert and oriented to time, place, and person. A.B. has appropriate muscle strength and tone. All the 12 Cranial nerves are intact and functioning optimally.

Psychiatric:

A.B. is in a joyful mood. The effect is euthymic. A.B. seems to be anxious and concerned.

Lab Tests:

No lab tests have yet been ordered.

Special Tests:

No special tests are yet ordered.

DIAGNOSIS (minimum required differential and presumptive dx, can do more)

Differential Diagnoses

1. Major Depressive Disorder (MDD) with associated sexual dysfunction (ICD-10 Code: F32.0)

Major Depressive Disorder (MDD) is a mood disorder associated with persistent feelings of sadness, loss of interest and pleasure in activities, changes in appetite or weight, sleep problems, fatigue, feelings of worthlessness or guilt, distractibility, and suicidal thoughts (Rose et al., 2020). In the sexual dysfunction of MDD, people tend to experience loss of libido and sexual desire along with other depressive symptoms (Gonçalves et al., 2022). A.B.’s subjective complaints and objective findings meet the DSM-5 criteria for Major Depressive Disorder. The long-term low libido, something she is experiencing along with other depressive symptoms, is an indication that a mood disorder may have set in (Pyke, 2021). The presence of a flat expression, along with other somatic signs of depression in our client, confirms the validity of this diagnosis. Pyke (2021) notes that sexual dysfunction, for instance, loss of libido, is one of the physical symptoms of depression due to the adverse influence of these symptoms on mood, energy, and drive.

2. Adjustment Disorder with Mixed Anxiety and Depressed Mood (ICD-10 Code: F43.22)

Adjustment Disorder with Mixed Anxiety and Depressed Mood is marked by the development of these emotional or behavioral symptoms within three months of the appearance of stressors (Eberle & Maercker, 2021). These symptoms could be in the form of depressed mood, anxiety, and disruptions in interpersonal, occupational, and other essential areas of functioning. The subjective presentation of A.B. and physical findings suggest the possible diagnosis of Adjustment Disorder with Mixed Anxiety and Depressed Mood. Her sexual desire has historically been low when stress is at a high point, which is indicative of the characteristic emotional or behavioral reaction to identifiable stressors (Herasymenko et al., 2020). Similarly, the presence of emotional distress and impairment of functioning also meet the diagnostic criteria for Adjustment Disorder. Indeed, in this context, the libido decline may be associated with an adaptive coping strategy in providing the surge of anxiousness to the ongoing stressors.

3. Endocrine Disorders, such as Hyperprolactinemia, leading to decreased libido (ICD-10 Code: E22.9)

Disorders of the endocrine system, such as Hyperprolactinemia, are responsible for such symptoms as decreased libido (O’Leary, 2020). Hyperprolactinemia stands for higher than normal prolactin in the blood, which could be a consequence of pituitary tumors, medications, or specific medical issues. A.B. had a progressive decrease in her libido in the previous years without any specific reason or aggravating factors. She says there is no real difference in her mental health or relationships. This subjective symptom can hint at a probable underlying physiological factor, such as hormonal imbalance. Even though A.B.’s complaint of reduction in libido is a pointer towards a possible endocrine disorder like hyperprolactinemia, the fact that there are no overt physical signs on examination calls for more diagnostic assessment. Laboratory tests and serum prolactin levels, among other tests, could be applied to determine or rule out endocrine abnormalities. The abnormally elevated levels of prolactin can interrupt normal sexual functioning by interfering with the production of gonadotropin-releasing hormone (GnRH), which, in turn, reduces the release of sex hormones like testosterone and estrogen (Salvio et al., 2021). Therefore, A.B.’s sex drive can lower due to hormonal imbalance. The investigation and management of coexisting hidden endocrine diseases are fundamental in the treatment of the woman’s symptoms and the establishment of her sexual health.

Presumptive Diagnosis (ICD 10 code

Hypoactive Sexual Desire Disorder (HSDD) (ICD-10 Code: F52.0)

Hypoactive Sexual Desire Disorder (HSDD) manifests itself in a repeated or persistent absence/deficiency of sexual fantasies and desire for sexual relationships, leading to significant distress or interpersonal problems (Kingsberg et al., 2020). It is critical to differentiate HSDD from non-pathological situational or transient reductions in sexual desire that may result from various etiologic agents, such as relationship problems, stressors, or pathologic conditions. A.B. demonstrates an emotional state of distress with a flat affect and feelings of tension and concern toward her relations. In such a review of symptoms, depression and anxiety with symptoms of HSDD are detected, and the diagnosis of HSDD is approved. Moreover, A.B.’s subjective proclivities and objective findings give credence to the provisional diagnosis of Hypoactive Sexual Desire Disorder (HSDD). One of the essential diagnostic criteria of HSDD is low sexual desire that persists for a very long time and is accompanied by emotional distress and problems in interpersonal relationships (Pettigrew & Novick, 2021). The lack of account of known organic causes on examination reflects the psychological nature of her symptoms as the main etiology. Moreover, the presence of comorbid depressive and anxiety disorders further complicates her clinical picture, and thus, patient management becomes an even more complex and multidimensional process.

Plan/Therapeutics:

Comprehensive Assessment:

A comprehensive assessment of the client’s health profile, encompassing any co-morbid medical conditions, medications, and psychological factors underlying hypoactive sexual desire (Schuiling & Likis, 2020). Perform a physical exam to rule out any organic causes of sexual dysfunction and check for signs of hormone imbalances or related findings otherwise.

Psychotherapy:

Refer A.B. to an expert in sexual health or sex therapy who must be certified. Psychosocial determinants of erectile impairment, such as stress, anxiety, or negative thoughts about sex, could be treated by CBT or psychotherapy methods (Velten et al., 2020). Also, couples’ therapy, along with relevant relationship problems, can aid couples in learning how to communicate their sexual issues together.

Pharmacotherapy:

Pharmacological interventions for HSDD include flibanserin 100mg orally once a day before bed for an eight-week treatment to address hypoactive sexual desire disorder in premenopausal women (Vanderah, 2023). The pharmacotherapy benefits, risks, and side effects must be discussed with A.B., considering her medical history and individual preferences.

Hormone Therapy:

If it is clinically necessary, determine the test androgen hormones and estrogen levels. Hormonal replacement therapy (HRT) or other hormonal treatment methods can be used to cure women with hormonal deficiency who have hypoactive sexual desire, such as menopausal symptoms and androgen deficiency (Spielmans, 2021).

Lifestyle Modifications:

Inform A.B. to adopt healthy lifestyle habits like regular exercise, enough sleep, stress management and proper diet (Da Silva Lara et al., 2021). Identify and deal with the modifiable risk factors for sexual dysfunction, which include substance abuse, smoking, or too much consumption of alcohol.

Education and Counseling:

Educate A.B. about the hypoactive sexual desire disorder (Pesantez & Clayton, 2021).

Collaborative Care:

Liaise with therapists, gynecologists, and endocrinologists to ensure A.B. gets attention to their sexual health and overall well-being (Thurston et al., 2022).

Diagnostics:

Psychological Assessment:

Evaluate the psychological factors that can lead to low libido, like depression, anxiety, PTSD, and bad relationships (Friedmann & Cwikel, 2021). For assessment of the presence and severity of psychological symptoms as well as their influence on sexual function, apply validated screening or questionnaire tools.

Diagnostic Criteria:

Apply the diagnostic criteria of HSDD described in the DSM-5 or with other standardized diagnostic systems (Hamzehgardeshi et al., 2020). Validate persistently or regularly a lack of sexual fantasies and desires, which are followed by marked distress or relationship problems, to prevent a wrong HSDD diagnosis.

Specialized Testing:

Apart from the pelvic sonogram, MRI magnetic resonance imaging is necessary in case of any anatomical anomaly or structural changes to sexual function (Weber & Odin, 2022). Collaborate with urologists or reproductive endocrinologists so that the physician can refer complicated or persistent cases for accurate diagnosis and treatment.

Laboratory Tests:

Perform blood tests that determines hormone levels, such as testosterone, estrogen, diabetes, and prolactin and to also rule out high cholesterol and liver disorders that may be causing HSSD (Maseroli et al., 2023a). Endocrine system diseases such as low testosterone or high prolactin can be associated with low libido; hence, they need to be investigated accurately.

Collaborative Approach:

Work collaboratively with A.B. to select the diagnostic tests that match the clinical assessment, patient preference, and treatment goals (Ramlachan & Naidoo, 2024). Where appropriate, collaborate with other healthcare professionals, including psychologists, gynecologists, and endocrinologists, to ensure that A.B. gets the best medical and psychological support for their sexual health and general well-being (Fantasia et al., 2020).

Sexual History:

Conduct a comprehensive sexual history, which includes information on the functioning, satisfaction, and dynamics of relationships (Ronghe et al., 2023). Find out how often and healthy sex takes place, the quality of sexual arousal, whether orgasm can be reached or not, and any problems that may appear in relationships.

Pelvic Exam:

Performing a pelvic exam in this case is essential to exclude underlying organic causes of sexual dysfunction, such as gynecological abnormalities or hormonal imbalances (Wheeler & Guntupalli, 2020). It helps to define genital anatomy, diagnose gynecological disorders, and assess the pelvic floor function, all of which can lead to the development of hypoactive sexual desire disorder (HSDD).

Education Provided:

Understanding Hypoactive Sexual Desire Disorder (HSDD):

Define for A.B. the meaning of HSDD as well as diagnostic criteria for it as a medical condition where a person faces constant or periodical absence of sexual fantasies and desire that may contribute to stress or interpersonal problems (Maseroli et al., 2023a). HSDH does not mean indifference to the sex of an individual; instead, it is a combination of biological, psychological, and interpersonal factors which determine the level of sexual interest.

Normalizing Sexual Desire Variability:

Inform A.B. that sexual desire can vary a lot between people and their relationship partners, so it can be influenced by many factors besides sex, like stress, tiredness, or relationship issues (Dewitte et al., 2020). Tell A.B. that fluctuating sexual appetite is a usual matter, and it is okay to ask for assistance if it worries him or causes disruption.

Exploring Contributing Factors:

Such an individual may have a decreased desire for sexual activity for several reasons, including hormonal imbalances, psychological stress, relationship issues, or a medical condition (De Oliveira et al., 2023). Encourage open dialogue and examination of any fears and obstacles that may affect sexual motivation, making the medical platform non-judgmental, accepting space where A.B. fully expresses herself (Cash, 2023).

Psychoeducation on Treatment Options:

Provide a detailed overview of handling HSDD, including psychotherapy, pharmacotherapy, hormone therapy, and lifestyle modifications (Uloko et al., 2022). Discuss each modality’s advantages and disadvantages, including potential limitations, and how they suit A.B.’s requirements, wishes, and goals (Fantasia et al., 2020).

Couples Communication and Intimacy Enhancement:

Advise on raising communication and intimacy levels in a couple’s relationship wherein open dialogue, mutual understanding, and shared responsibility are highlighted (Wang et al., 2022). Make resources or referrals for couples therapy or relationship counseling available to address problems like interpersonal conflicts or communication obstacles that may affect sexual intimacy.

Stress Management and Self-Care Strategies:

Educate A.B. on stress management techniques and self-care practices for comprehensive wellness and improved sexual health (McClung et al., 2023). Prompt the acceptance of the healthy way of living, which includes regular exercise, enough sleep, meditation, and mindfulness, and these can be utilized to relieve stress and enhance mood and energy levels.

Follow-Up and Support:

Stress the necessity of continuous follow-up and support in managing HSDD, telling the female that she does not have to bear the problems of sexual health and wellbeing alone (Cocchetti et al., 2021). Inform A.B. about the various support groups, online resources, and community organizations for individuals with sexual concerns and give additional education, empowerment, and peer support options.

Onset:
The irregular menses and accompanying pains began about three months ago, which was at the time of her last menstrual period. The onset was gradual, with symptoms deteriorating progressively over the previous three menstrual cycles.
Location:
The pain is mainly in the lower abdomen, bilaterally. B.D. describes the pain as diffuse, and most pain is focused on the lower pelvic region.
Duration:
The symptoms of irregular periods and severe menstrual cramps have been continuing for the last three months. The pain usually starts several days before the beginning of menstruation and lasts throughout the menstrual period, gradually decreasing after that.
Character:
The pain is described as crampy and sharp, with intervals of acute discomfort. Pain intensity varies but is usually rated 8 out of 10 numerically. B.D. complains that the pain is so unbearable that it interferes with her daily activities, and she has to use over-the-counter medications frequently to get some relief.
Aggravating factors:
Pain increases during menstruation, reaching its highest level on the first and second days of the menstrual cycle. Movement adds to the pain, especially when bending or lifting heavy loads.
Relieving factors:
B.D. uses ibuprofen 400mg TDS (three times a day) orally, which is moderately helpful in reducing menstrual pain. Also, B.D. feels much better when lying and applying heat to the lower abdomen.
Timing:
The symptoms occur cyclically, coinciding with the B.D.’s menstrual cycles. The pain usually begins a few days before menstruation and continues during the menstrual period, 5-7 days in total.

B.D. takes ibuprofen 400mg orally, TDS as needed for menstrual pain relief.

Medication Intolerances: No medication intolerances were reported.
Past Medical History (PMH)  

No chronic illnesses or major traumas were mentioned.
Hospitalizations/Surgeries:
No past hospitalizations or surgeries.

Surgery:

No prior history with surgery.

B.D.’s mother passed away at 78 years old from cardiac arrest.

MGM (Maternal Grandmother):

B.D.’s maternal grandmother died at the age of 75 from tuberculosis complications.

MGF (Maternal Grandfather):

Maternal Grandfather died at age 86 after a stroke.
F (Father): Father is still alive at the age of 73, with a history of hypertension.

PGM (Paternal Grandmother):

B.D.’s paternal grandmother is 83 years old and has a history of depression.
PGF (Paternal Grandfather):

B.D.’s paternal grandfather, passed away at 67 due to gastric cancer.

No use of illegal substances and drugs.

Marital Status:

Married.

Sexual Activity:

·       Not sexually active

Gender Identity:

·       Female

Sexual Orientation:

Either straight or heterosexual

Occupation:

Data analyst, works from home.

Nutrition History:

Optimal nutritional status.

Family Support:

She has a brother and a husband who are very supportive. She has two children: a boy and a girl.

LMP: 02/16/2024. She previously had irregular menses.

65 kg

B.D. is well dressed and well nourished. She seems worried and concerned about her irregular menses.

On inspection, the head is normocephalic and atraumatic.

Her eyes are symmetrically placed within the orbits. Equal, round, and phototropic.

There is no inflammation, swelling, or tenderness around the ears. Extraocular movements are intact. Tympanic membranes clear bilaterally.

Primary Dysmenorrhea ICD-10 code: N94.4:
Primary dysmenorrhea is a common gynecological condition that refers to painful menstrual cramps associated with no pelvic pathology. This diagnosis is relevant to the B.D.’s chief complaint of irregular menstruation and severe menstrual pain for the past three months (Itani et al., 2022). The symptoms began around the time of the B.D.’s last menstrual period, supporting a cyclical profile consistent with primary dysmenorrhea. The subjective data demonstrates that B.D. Suffers from crampy and sharp pain in the lower abdomen, with an 8 out of 10 intensity on the visual analogue scale. The pain is more severe during menstruation, reaching its peak on the first and second days of the menstrual period (Jiang et al., 2023).

Additionally, B.D. gets relief from the symptoms by resting and applying heat to the lower abdomen, which are frequent self-management strategies for primary dysmenorrhea.
Endometriosis (ICD-10 code: (N80.9): Endometriosis is a persistent gynecological ailment distinguished by tissue resembling the endometrium outside the uterus, prevalent in the pelvic cavity. Patients’ symptoms may also indicate endometriosis as an essential consideration due to its relationship with issues such as irregular menstruation and severe menstrual pain (Smolarz et al., 2021). B.D.’s history of a worsening 3-month-long pelvic pain localized to the lower abdomen and aggravated by menstruation matches the typical presentation of endometriosis syndrome. Moreover, there are similarities in terms of crampy and sharp pain, which correspond to the menstrual cramps that pain individuals with endometriosis. Endometriosis can cause infertility, and for a patient of this age, this may be very alarming (Rodrigues et al., 2020). Although the ultimate diagnosis of endometriosis is determined most typically through laparoscopy, the notion of endometriosis in diagnosing B.D. is a necessary consideration in developing additional diagnostic evaluation and treatment recommendations.
Pelvic Inflammatory Disease (PID) (ICD-10 code: (N70.9): PID is an infectious condition that involves inflammation of the female reproductive organs, such as ovaries, fallopian tubes, and the uterus. It is often associated with organisms transmitted through sexual routes, such as Chlamydia trachomatis or Neisseria gonorrhoeae. B.D.’s manifestations, such as pelvic pain, irregular menses, and dysmenorrhea, would raise the chances of PID, given that the possibility of a recent or concurrent sexually transmitted infection could be the underlying cause (Greydanus et al., 2022). Although she denies any recent new sexual activities, PID is one of the differential diagnoses for symptoms such as irregular menses and pelvic pain, which are the same as her reported complaints. Furthermore, PID engenders chronic post-infectious syndromes such as infertility; therefore, early diagnosis and treatment are significant key components (Britto et al., 2023). As such, to make an accurate diagnosis and exclude other diagnoses of pelvic inflammatory disease, an extensive diagnostic evaluation, pelvic examination, and testing for sexually transmitted infections are needed for this patient.

Irregular menstruation, unspecified (N92.6)
Irregular menstruation is considered the presumptive diagnosis for B.D., a 32-year-old African American female. B.D. has complained of continuous irregular menstrual cycles and acute menstrual pain lasting three months before her visit. The subjective report includes irregular menstrual cycles, heavier cycles than usual, and severe cramping, severe localized pain in the lower abdomen during menstruation. The presented signs of longer bleeding time than usual and aggravation of pain during menstruation correctly define the diagnosis (Abreu-Sánchez et al., 2020). These signs and symptoms are corroborated with typical vital signs and physical examination results, showing the absence of any acute abnormalities. The absence of palpable masses or tenderness in the abdominal examination signifies that the irregularity in menstrual cycles is not because of structural pathology or underlying pathology but rather a functional or hormonal issue (Fredette, 2020). Additional evaluation is thus required to identify the possible reasons, such as an imbalance of hormones or thyroid disorders, and this will facilitate the development of a management plan built according to B.D.s needs, with hormone therapy and lifestyle modifications being considered, among other treatment options that address any underlying medical conditions.

Lifestyle Modifications: Encourage B.D. to follow healthy lifestyle habits such as regular exercising, a balanced diet, and stress reduction activities like yoga or meditation (Aggarwal et al., 2022). Regular physical activity can improve blood circulation and reduce muscle tension, thus mitigating the severity of menstrual cramps. A healthy diet can also support overall well-being and hormone balance.
Pharmacological Interventions: Advise patients that NSAIDs, for example, naproxen 500mg orally and QID for the duration of the treatment, could be used to medicate menstruation pain (Vanderah, 2023). NSAIDs block prostaglandin formation, thereby decreasing uterine contractions and relaxing menstrual pain. Instruct B.D. to take NSAIDs according to the instructions on the packaging or as directed by a healthcare professional.
Hormonal Therapy: Consider the option of providing hormonal contraceptives such as combined oral contraceptives (COCs) 20 mcg daily to regulate menstrual bleeding and lessen the fibroid’s size to women to regulate menstrual cycles and decrease the severity of menstrual pain (Vanderah, 2023). Hormonal contraceptives may inhibit ovulation and decrease the endometrium thickness; therefore, periods become lighter and less painful.

Referral to Specialist: A referral to a specialist like a gynecologist or a reproductive endocrinologist may be required to investigate and manage the underlying cause of irregular menstruation, N92.6, in B.D. A thorough evaluation can offer specialist expertise in diagnosing and treating complex gynecological conditions, and individualized care ensures better outcomes for B.D.’s menstrual health.

Menstrual Diary: This is the first diagnostic modality I will start with. I will request that B.D. makes a diary in which she should note the start date, duration, and characteristics of menstrual bleeding and associated symptoms for at least 3-4 consecutive cycles (Habiba & Benagiano, 2023). A menstrual diary delivers precious information on the regularity of the menstruation cycle, the intensity and duration of menstrual pain, and possible changes or routine patterns. It can help establish the diagnosis of the primary one and monitoring treatment results.
Laboratory Tests: Additionally, I will run laboratory tests, including the CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel), to check for anaemia, electrolyte imbalance, and other systemic problems (Deyrup et al., 2022). Laboratory tests help identify conditions that contribute to menstrual irregularities or the intensification of symptoms of dysmenorrhea, for example, iron deficiency anaemia. Abnormal CBC or CMP values might require further evaluation and testing.
Diagnostic Laparoscopy: Diagnostic laparoscopy should be considered for patients with suspected endometriosis or other pelvic disorders unresponsive to conservative management or with atypical presentations (Horne & Missmer, 2022). Laparoscopy allows direct visualization and biopsy of the pelvic structures and can definitively diagnose endometriosis or other intra-abdominal pathologies. It is used for treatment planning and could be a basis for surgical interventions.

Pelvic Exam: Additionally, a pelvic examination is done with this patient to check the status and health of her reproductive organs, such as the uterus, ovaries, and cervix. It can detect any structural anomalies, including fibroids or other cysts, that might be related to her irregular menstruation and painful periods.
Endometrial Biopsy: Lastly, I will perform endometrial biopsy in postmenopausal women or those with abnormal uterine bleeding to exclude endometrial hyperplasia or malignancy (Papakonstantinou & Adonakis, 2021). Endometrial biopsy helps rule out secondary causes of abnormal uterine bleeding and menstrual irregularities such as endometrial cancer. It is noted in patients with prolonged or severe symptoms even after the appropriate management of irregular menstruation.