Assignment Prompt & Instructions
see attachment
– ## Week8Response2.pdf
**## Week8Response2.pdf**
Case Scenario 2
Table 1
Table 2
Term Definition
Sexuality
a person's capacity for sexual feelings, orientation, preferences, and
behaviors that reflect their sexual and romantic interests.
Sexual health
a state of physical, emotional, mental, and social well-being in
relations to sexuality; not merely the absence of disease or
dysfunction.
Sexual identity
how 1 perceives oneself in terms of sexuality and how they identify
such as heterosexual, homosexual, bisexual, asexual
Sexual orientation
a person's emotional, romantic, or sexual attraction to others such as
gay, lesbian, straight, bisexual, pansexual.
Sexual agency
to ability to make decisions and exercise control over 1's own sexual
activity and relationships, including the right to consent and refuse
Sex
the biological classification of individuals as male, female, or
intersex based on anatomy, chromosomes, and hormones.
Gender Identity
one's internal sense of being male, female, a blend of both, neither,
or another gender, which may or may not align with their sex
assigned at birth.
Transgender
A term for individuals whose gender identity differ firm these sex
they were assigned at birth
Gender dysphoria
psychological distress that results firm in incongruence between
ones sexually assigned at birth and their gender identity
Cisgender
a term for individuals who gender identity matches these sex they
were assigned at birth
Transmale
a person who was assigned female at birth but identifies and lives as
male; Also referred to as a transgender man.
Transfemale
a person who was assigned male at birth but identifies and lives as
female also referred to as a transgender woman
Name 5 medical (physical) causes of female 1 Diabetes, 2 cardiovascular disease. 3
hypothyroidism. 4 Vaginal atrophy/
Table 3
Name 5 medication-induced sexual
dysfunction
1. Selective serotonin reuptake inhibitors
(SSRIs)2. Antihypertensives (e.g., beta-
blockers)3. Antipsychotics4. Oral
contraceptives5. Benzodiazepines
Name 5 psychological cases of female sexual
dysfunction
1. Depression2. Anxiety disorders3. History of
sexual trauma4. Relationship conflict or
intimacy issues5. Low self-esteem or body
image issues
Name at least 4 management plan to help
with sexual dysfunction (include 2
pharmacologic and 2 non pharmacologic
interventions)
Pharmacologic:1. Flibanserin (Addyi) for
premenopausal women with hypoactive sexual
desire disorder2. Vaginal estrogen (e.g.,
estradiol cream) for GSMNon-
pharmacologic:3. Sex therapy or couples
counseling4. Use of lubricants or moisturizers
for vaginal dryness
Define Vulvodynia: Vulvodynia is chronic vulvar pain lasting at least three months, without an
identifiable cause. It may be constant or intermittent and is often described as burning, stinging,
irritation, or rawness in the vulvar area.
Define Vaginismus: Vaginismus is the involuntary contraction or spasm of the pelvic floor
muscles surrounding the vagina, making vaginal penetration painful, difficult, or impossible. It
is often associated with fear or anxiety about intercourse.
What is the difference between the 2 diagnoses? Vulvodynia is characterized by persistent
vulvar pain without a clear physical cause, whereas vaginismus involves involuntary muscle
contractions that prevent vaginal penetration. Vulvodynia is primarily a pain disorder, while
vaginismus is a muscular response often related to anxiety or past trauma.
Ty is 22-year-old who comes to your office for an annual physical exam. On the intake
paperwork, you note the gender box is blank. Ty was female assigned as birth but identifies as
They/Them. The patient selected both the “have sex with females” and the “have sex with
males” box in the sexual history.
SOAP NOTE
Demographic: 22-year-old assigned female at birth, identifies as nonbinary (they/them
pronouns). Sexually active with males and females.
SUBJECTIVE
Chief Complaint (CC): “Here for annual check-up”
HPI: Ty is a 22-year-old individual assigned female at birth who identifies as nonbinary and uses
they/them pronouns. Ty presents for an annual physical exam. They completed intake paperwork,
leaving the gender box blank, but indicated sexual activity with both males and females. Ty
reports engaging in consensual sexual activity with multiple partners and states condom use is
inconsistent. They deny any current symptoms such as abnormal vaginal discharge, pelvic pain,
genital lesions, or urinary symptoms. No known history of STIs. No history of contraception use,
hormone therapy, or gender-affirming medical treatment. No menstrual concerns reported. Ty
denies current medical concerns and appears in good general health. Denies chest pain, fatigue,
unintentional weight loss, or gastrointestinal symptoms. They report experiencing general life
stress due to school and work balance but deny symptoms of depression or anxiety at this time.
Ty verbalizes satisfaction with current gender expression and sexual identity, although they
express concern about whether health screenings are appropriate based on their gender identity.
Gynecological History
LMP: May 28, 2025 (approximate; patient reports regular cycles)
Menarche: Age 12; Cycle: Every 28–32 days, lasts 4–5 days, moderate flow, no dysmenorrhea
Pap Smear History: Never done; first due now (per USPSTF)
STI History: Denies history of STIs; no testing done in past 12 months
Contraceptive History: Never used hormonal or non-hormonal contraception
What are treatment options? For Vulvodynia: Topical lidocaine, Tricyclic antidepressants (e.g.,
amitriptyline), Pelvic floor physical therapy– Cognitive behavioral therapy (CBT). For
Vaginismus: Pelvic floor therapy with dilator training, Behavioral sex therapy, Psychotherapy
to address underlying psychological causes– Education and relaxation techniques.
Sexual History: Sexually active with both male and female partners, No pain, bleeding, or
discomfort with intercourse, No history of sexual trauma
Prior Pregnancies: G0P0
Vaginal Health: Denies itching, discharge, dryness, or odor, No recurrent infections or concerns
with vaginal hygiene
PAST MEDICAL HISTORY
Asthma (childhood, resolved)
PAST SURGICAL HISTORY
None Reported
FAMILY HISTORY
Mother
Hypertension
Type 2 diabetes mellitus
Overweight/obesity
Father
Hyperlipidemia
Smoker (20+ years)
Maternal Grandmother
Breast cancer (diagnosed in her 60s)
Osteoporosis
Maternal Grandfather
Deceased (stroke at 72)
History of Heart Disease
Paternal Grandmother
Alzheimer’s disease
Paternal Grandfather
Type 2 diabetes
History of prostate cancer
Sibling(s):
Youngest brother 18, no issues and healthy.
Current Medications:
None prescribed.
Denies use of over-the-counter medications, herbal supplements, or vitamins at this time.
Allergies:
Denies any drugs, food, or environmental allergies.
Social History:
Home: Lives with roommates; Education/Employment: College student, part-time job;
Activities: Active socially, regular exercise; Drugs/Alcohol: Drinks alcohol socially, denies
tobacco or drug use; Sexuality: Sexually active with males and females; uses condoms
inconsistently
Review of Systems (ROS)
General: Denies fever, chills, night sweats, fatigue, or unintentional weight loss or gain.
HEENT: Denies headaches, vision changes, ear pain, hearing loss, nasal congestion, sore throat,
or oral lesions.
Cardiovascular: Denies chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea,
edema, or history of hypertension.
Respiratory: Denies cough, shortness of breath, wheezing, or history of asthma in recent years.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, heartburn, or
changes in appetite or bowel habits.
Genitourinary: Denies dysuria, frequency, urgency, hematuria, pelvic pain, or abnormal vaginal
discharge or bleeding. No history of STIs reported. Denies urinary incontinence.
Musculoskeletal: Denies joint pain, swelling, stiffness, back pain, or limitations in movement.
Neurological: Denies dizziness, lightheadedness, numbness, tingling, weakness, seizures, or
syncope.
Integumentary (Skin & Breasts): Denies rashes, lesions, pruritus, or changes in skin or nails.
Denies breast pain, lumps, or discharge.
Endocrine: Denies heat or cold intolerance, polydipsia, polyuria, or polyphagia.
Hematologic/Lymphatic: Denies easy bruising, prolonged bleeding, swollen lymph nodes, or
history of anemia.
Psychiatric: Denies current depression, anxiety, mood swings, sleep disturbance, or suicidal
ideation. Reports some mild stress due to work/school balance, but coping well. Denies history
of psychiatric hospitalization.
Allergic/Immunologic: Denies seasonal allergies, food allergies, or autoimmune symptoms.
Denies history of immunodeficiency.
OBJECTIVE
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood Pressure: 112/74 mmHg; Heart Rate: 72 bpm; Respirations: 16/min;
SaO₂: 99% on room air; Temperature: 98.6°F; Weight: 152 lbs; Height: 5’7”; BMI: 23.8 (within
normal range)
PHYSICAL EXAMINATION FINDINGS:
CONSTITUTIONAL/GENERAL APPEARANCE: Vital signs stable, in no acute distress. Alert,
well-developed, well-nourished.
HEENT:
Head: Atraumatic, normocephalic.
Eyes: Sclerae white, conjunctivae and lashes clear. No lid lag. EOMI. PERRLA.
• ENT: Mucous membranes pink, moist, intact; External ear canals clear, no cerumen;
Tympanic membranes clear, pearly gray with good light reflex; Hearing intact to whisper;
Nares patent, mucosa pink and moist; Mouth, lips, tongue, and gums intact, no lesions; Good
dentition; hard and soft palates intact; tongue and uvula midline
NECK: Supple. No JVD, thyromegaly, or lymphadenopathy.
RESPIRATORY/CHEST: Unlabored respiration. Chest rise equal and symmetric. Lungs clear to
auscultation (CTA) bilaterally. No adventitious sounds.
CARDIOVASCULAR: S1, S2 normal. No murmurs, rubs, or gallops appreciated.
BREASTS: Skin intact, no lesions, masses, or rashes. No nipple discharge. Breasts symmetric
with no dimpling, retractions, or peau d’orange.
GI (Abdomen): Normoactive bowel sounds. No hepatosplenomegaly, tenderness, masses, or
hernias.
GENITAL/RECTAL (External exam only if consented): No suprapubic tenderness or bladder
distention. No external lesions, rashes, swelling, or masses.
LYMPH NODES: No lymphadenopathy in cervical, axillary, or inguinal regions.
MUSCULOSKELETAL: Gait and station within normal limits. Full range of motion in all joints.
Strength and tone 5/5 throughout. Symmetric arm swing.
INTEGUMENTARY: Skin warm, intact, and well-perfused. No rashes, lesions, or abnormal
discoloration. Nails healthy.
EXTREMITIES: No cyanosis, clubbing, or edema. Pulses +2 in radial and pedal arteries
bilaterally.
NEUROLOGICAL: Cranial nerves II–XII grossly intact. DTRs +2 and symmetric. Sensation
intact to light touch. No motor or sensory deficits.
PSYCHIATRIC: Alert and oriented ×3. Mood and affect appropriate. Judgment and insight
within normal limits. No signs of distress, paranoia, or abnormal behavior.
ASSESSMENT:
Differential Diagnoses
1. Encounter for screening for infections with a predominantly sexual mode of
transmission (ICD-10 Z11.3)
Rationale for Consideration: Given Ty’s report of sexual activity with both male and female
partners and inconsistent use of condoms, screening for STIs is appropriate.
Why not chosen as Final Diagnosis: This code is used to indicate the purpose of the visit only
if STI screening is the primary reason. In Ty’s case, the visit is a comprehensive annual physical,
not focused solely on STI risk or symptoms.
Pertinent Positives:
Sexually active with multiple partners
Inconsistent Condom use
Pertinent Negative:
No current genital symptoms
No known prior STIs
No systemic signs of infection
2. High Risk Homosexual Behavior (ICD-10 Z72.52)
Rationale for Consideration: Used to indicate behaviors that increase risk for health conditions
such as STIs, HIV. Ty reports sex with both female and male partners and inconsistent protection.
Why Not Chosen as Final Diagnosis: This diagnosis may be used in more targeted risk-focused
or behavioral intervention visits. It is not appropriate for a routine, comprehensive exam unless
counseling is the primary focus.
Pertinent Positives:
Sexually active with both male and female
Inconsistent use of protection
Pertinent Negatives:
No current behavioral health concerns
No engagement in transactional sex or high risk exposure
FINAL DIAGNOSIS
Encounter for gynecological examination (general) (routine) without abnormal findings
(ICD-10: Z01.419)
Rationale: Ty is a 22-year-old nonbinary individual assigned female at birth who presents for a
routine annual physical that includes gynecological screening, notably a first-time Pap smear.
The visit is preventive in nature, with no abnormal findings reported in the review of systems or
physical exam. This diagnosis code is appropriate per ICD-10-CM guidelines when a patient
undergoes a general or routine gynecological examination, including screening procedures such
as Pap smears, without symptoms or abnormal clinical findings.
Pertinent Positives:
Sexually active with male and female partners → appropriate STI and cervical cancer screening.
First gynecologic screening, appropriate timing and preventive context. No previous Pap smear
documented, initiation of baseline screening.
LMP and menstrual history consistent with normal function
Pertinent Negatives:
Denies abnormal vaginal bleeding, discharge, or pelvic pain
No history of STIs or reproductive tract infections
No dysuria, urinary frequency, or suprapubic tenderness
No cervical or uterine tenderness, masses, or structural abnormalities
No cervical or uterine tenderness, masses, or structural abnormalities
PLAN
Labs Ordered:
Pap smear – for cervical cancer screening (per USPSTF guidelines for individuals with a cervix
starting at age 21)
STI screening labs:
Urine GC/CT NAAT – for chlamydia and gonorrhea
HIV antigen/antibody combo
RPR – for syphilis
Hepatitis B surface antigen (HBsAg)
Hepatitis C antibody
Pregnancy test (urine hCG) – precautionary due to sexual activity with male partners
MEDICATIONS AND TREATMENT:
None prescribed today.
Ty is not currently seeking contraception and is not on hormone therapy. May consider PrEP
counseling if future behavior or exposure risk increases.
REFERRALS AND FOLLOW UPS:
No specialty referral needed at this time.
Return to clinic:
Pap smear results and STI screening follow-up (2–3 weeks)
Annual Exam in 1 year
PATIENT EDUCATION:
Explained purpose and importance of Pap smear screening beginning at age 21 and continuing
every 3 years if normal
Discussed STI risks and the importance of regular screening despite absence of symptoms
Encouraged consistent barrier protection with all partners, regardless of gender
Discussed vaccine preventable STIs (Hepatitis B, HPV – already completed HPV series)
Educated on the confidentiality of reproductive and sexual health care
Reviewed signs/symptoms that warrant urgent follow-up: fever, pelvic pain, abnormal discharge,
or post-coital bleeding
Provided support for gender-affirming care and inclusive communication
**## Week8Response2.pdf**
Case Scenario 2
Table 1
Table 2
Term Definition
Sexuality
a person's capacity for sexual feelings, orientation, preferences, and
behaviors that reflect their sexual and romantic interests.
Sexual health
a state of physical, emotional, mental, and social well-being in
relations to sexuality; not merely the absence of disease or
dysfunction.
Sexual identity
how 1 perceives oneself in terms of sexuality and how they identify
such as heterosexual, homosexual, bisexual, asexual
Sexual orientation
a person's emotional, romantic, or sexual attraction to others such as
gay, lesbian, straight, bisexual, pansexual.
Sexual agency
to ability to make decisions and exercise control over 1's own sexual
activity and relationships, including the right to consent and refuse
Sex
the biological classification of individuals as male, female, or
intersex based on anatomy, chromosomes, and hormones.
Gender Identity
one's internal sense of being male, female, a blend of both, neither,
or another gender, which may or may not align with their sex
assigned at birth.
Transgender
A term for individuals whose gender identity differ firm these sex
they were assigned at birth
Gender dysphoria
psychological distress that results firm in incongruence between
ones sexually assigned at birth and their gender identity
Cisgender
a term for individuals who gender identity matches these sex they
were assigned at birth
Transmale
a person who was assigned female at birth but identifies and lives as
male; Also referred to as a transgender man.
Transfemale
a person who was assigned male at birth but identifies and lives as
female also referred to as a transgender woman
Name 5 medical (physical) causes of female 1 Diabetes, 2 cardiovascular disease. 3
hypothyroidism. 4 Vaginal atrophy/
Table 3
Name 5 medication-induced sexual
dysfunction
1. Selective serotonin reuptake inhibitors
(SSRIs)2. Antihypertensives (e.g., beta-
blockers)3. Antipsychotics4. Oral
contraceptives5. Benzodiazepines
Name 5 psychological cases of female sexual
dysfunction
1. Depression2. Anxiety disorders3. History of
sexual trauma4. Relationship conflict or
intimacy issues5. Low self-esteem or body
image issues
Name at least 4 management plan to help
with sexual dysfunction (include 2
pharmacologic and 2 non pharmacologic
interventions)
Pharmacologic:1. Flibanserin (Addyi) for
premenopausal women with hypoactive sexual
desire disorder2. Vaginal estrogen (e.g.,
estradiol cream) for GSMNon-
pharmacologic:3. Sex therapy or couples
counseling4. Use of lubricants or moisturizers
for vaginal dryness
Define Vulvodynia: Vulvodynia is chronic vulvar pain lasting at least three months, without an
identifiable cause. It may be constant or intermittent and is often described as burning, stinging,
irritation, or rawness in the vulvar area.
Define Vaginismus: Vaginismus is the involuntary contraction or spasm of the pelvic floor
muscles surrounding the vagina, making vaginal penetration painful, difficult, or impossible. It
is often associated with fear or anxiety about intercourse.
What is the difference between the 2 diagnoses? Vulvodynia is characterized by persistent
vulvar pain without a clear physical cause, whereas vaginismus involves involuntary muscle
contractions that prevent vaginal penetration. Vulvodynia is primarily a pain disorder, while
vaginismus is a muscular response often related to anxiety or past trauma.
Ty is 22-year-old who comes to your office for an annual physical exam. On the intake
paperwork, you note the gender box is blank. Ty was female assigned as birth but identifies as
They/Them. The patient selected both the “have sex with females” and the “have sex with
males” box in the sexual history.
SOAP NOTE
Demographic: 22-year-old assigned female at birth, identifies as nonbinary (they/them
pronouns). Sexually active with males and females.
SUBJECTIVE
Chief Complaint (CC): “Here for annual check-up”
HPI: Ty is a 22-year-old individual assigned female at birth who identifies as nonbinary and uses
they/them pronouns. Ty presents for an annual physical exam. They completed intake paperwork,
leaving the gender box blank, but indicated sexual activity with both males and females. Ty
reports engaging in consensual sexual activity with multiple partners and states condom use is
inconsistent. They deny any current symptoms such as abnormal vaginal discharge, pelvic pain,
genital lesions, or urinary symptoms. No known history of STIs. No history of contraception use,
hormone therapy, or gender-affirming medical treatment. No menstrual concerns reported. Ty
denies current medical concerns and appears in good general health. Denies chest pain, fatigue,
unintentional weight loss, or gastrointestinal symptoms. They report experiencing general life
stress due to school and work balance but deny symptoms of depression or anxiety at this time.
Ty verbalizes satisfaction with current gender expression and sexual identity, although they
express concern about whether health screenings are appropriate based on their gender identity.
Gynecological History
LMP: May 28, 2025 (approximate; patient reports regular cycles)
Menarche: Age 12; Cycle: Every 28–32 days, lasts 4–5 days, moderate flow, no dysmenorrhea
Pap Smear History: Never done; first due now (per USPSTF)
STI History: Denies history of STIs; no testing done in past 12 months
Contraceptive History: Never used hormonal or non-hormonal contraception
What are treatment options? For Vulvodynia: Topical lidocaine, Tricyclic antidepressants (e.g.,
amitriptyline), Pelvic floor physical therapy– Cognitive behavioral therapy (CBT). For
Vaginismus: Pelvic floor therapy with dilator training, Behavioral sex therapy, Psychotherapy
to address underlying psychological causes– Education and relaxation techniques.
Sexual History: Sexually active with both male and female partners, No pain, bleeding, or
discomfort with intercourse, No history of sexual trauma
Prior Pregnancies: G0P0
Vaginal Health: Denies itching, discharge, dryness, or odor, No recurrent infections or concerns
with vaginal hygiene
PAST MEDICAL HISTORY
Asthma (childhood, resolved)
PAST SURGICAL HISTORY
None Reported
FAMILY HISTORY
Mother
Hypertension
Type 2 diabetes mellitus
Overweight/obesity
Father
Hyperlipidemia
Smoker (20+ years)
Maternal Grandmother
Breast cancer (diagnosed in her 60s)
Osteoporosis
Maternal Grandfather
Deceased (stroke at 72)
History of Heart Disease
Paternal Grandmother
Alzheimer’s disease
Paternal Grandfather
Type 2 diabetes
History of prostate cancer
Sibling(s):
Youngest brother 18, no issues and healthy.
Current Medications:
None prescribed.
Denies use of over-the-counter medications, herbal supplements, or vitamins at this time.
Allergies:
Denies any drugs, food, or environmental allergies.
Social History:
Home: Lives with roommates; Education/Employment: College student, part-time job;
Activities: Active socially, regular exercise; Drugs/Alcohol: Drinks alcohol socially, denies
tobacco or drug use; Sexuality: Sexually active with males and females; uses condoms
inconsistently
Review of Systems (ROS)
General: Denies fever, chills, night sweats, fatigue, or unintentional weight loss or gain.
HEENT: Denies headaches, vision changes, ear pain, hearing loss, nasal congestion, sore throat,
or oral lesions.
Cardiovascular: Denies chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea,
edema, or history of hypertension.
Respiratory: Denies cough, shortness of breath, wheezing, or history of asthma in recent years.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, heartburn, or
changes in appetite or bowel habits.
Genitourinary: Denies dysuria, frequency, urgency, hematuria, pelvic pain, or abnormal vaginal
discharge or bleeding. No history of STIs reported. Denies urinary incontinence.
Musculoskeletal: Denies joint pain, swelling, stiffness, back pain, or limitations in movement.
Neurological: Denies dizziness, lightheadedness, numbness, tingling, weakness, seizures, or
syncope.
Integumentary (Skin & Breasts): Denies rashes, lesions, pruritus, or changes in skin or nails.
Denies breast pain, lumps, or discharge.
Endocrine: Denies heat or cold intolerance, polydipsia, polyuria, or polyphagia.
Hematologic/Lymphatic: Denies easy bruising, prolonged bleeding, swollen lymph nodes, or
history of anemia.
Psychiatric: Denies current depression, anxiety, mood swings, sleep disturbance, or suicidal
ideation. Reports some mild stress due to work/school balance, but coping well. Denies history
of psychiatric hospitalization.
Allergic/Immunologic: Denies seasonal allergies, food allergies, or autoimmune symptoms.
Denies history of immunodeficiency.
OBJECTIVE
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood Pressure: 112/74 mmHg; Heart Rate: 72 bpm; Respirations: 16/min;
SaO₂: 99% on room air; Temperature: 98.6°F; Weight: 152 lbs; Height: 5’7”; BMI: 23.8 (within
normal range)
PHYSICAL EXAMINATION FINDINGS:
CONSTITUTIONAL/GENERAL APPEARANCE: Vital signs stable, in no acute distress. Alert,
well-developed, well-nourished.
HEENT:
Head: Atraumatic, normocephalic.
Eyes: Sclerae white, conjunctivae and lashes clear. No lid lag. EOMI. PERRLA.
• ENT: Mucous membranes pink, moist, intact; External ear canals clear, no cerumen;
Tympanic membranes clear, pearly gray with good light reflex; Hearing intact to whisper;
Nares patent, mucosa pink and moist; Mouth, lips, tongue, and gums intact, no lesions; Good
dentition; hard and soft palates intact; tongue and uvula midline
NECK: Supple. No JVD, thyromegaly, or lymphadenopathy.
RESPIRATORY/CHEST: Unlabored respiration. Chest rise equal and symmetric. Lungs clear to
auscultation (CTA) bilaterally. No adventitious sounds.
CARDIOVASCULAR: S1, S2 normal. No murmurs, rubs, or gallops appreciated.
BREASTS: Skin intact, no lesions, masses, or rashes. No nipple discharge. Breasts symmetric
with no dimpling, retractions, or peau d’orange.
GI (Abdomen): Normoactive bowel sounds. No hepatosplenomegaly, tenderness, masses, or
hernias.
GENITAL/RECTAL (External exam only if consented): No suprapubic tenderness or bladder
distention. No external lesions, rashes, swelling, or masses.
LYMPH NODES: No lymphadenopathy in cervical, axillary, or inguinal regions.
MUSCULOSKELETAL: Gait and station within normal limits. Full range of motion in all joints.
Strength and tone 5/5 throughout. Symmetric arm swing.
INTEGUMENTARY: Skin warm, intact, and well-perfused. No rashes, lesions, or abnormal
discoloration. Nails healthy.
EXTREMITIES: No cyanosis, clubbing, or edema. Pulses +2 in radial and pedal arteries
bilaterally.
NEUROLOGICAL: Cranial nerves II–XII grossly intact. DTRs +2 and symmetric. Sensation
intact to light touch. No motor or sensory deficits.
PSYCHIATRIC: Alert and oriented ×3. Mood and affect appropriate. Judgment and insight
within normal limits. No signs of distress, paranoia, or abnormal behavior.
ASSESSMENT:
Differential Diagnoses
1. Encounter for screening for infections with a predominantly sexual mode of
transmission (ICD-10 Z11.3)
Rationale for Consideration: Given Ty’s report of sexual activity with both male and female
partners and inconsistent use of condoms, screening for STIs is appropriate.
Why not chosen as Final Diagnosis: This code is used to indicate the purpose of the visit only
if STI screening is the primary reason. In Ty’s case, the visit is a comprehensive annual physical,
not focused solely on STI risk or symptoms.
Pertinent Positives:
Sexually active with multiple partners
Inconsistent Condom use
Pertinent Negative:
No current genital symptoms
No known prior STIs
No systemic signs of infection
2. High Risk Homosexual Behavior (ICD-10 Z72.52)
Rationale for Consideration: Used to indicate behaviors that increase risk for health conditions
such as STIs, HIV. Ty reports sex with both female and male partners and inconsistent protection.
Why Not Chosen as Final Diagnosis: This diagnosis may be used in more targeted risk-focused
or behavioral intervention visits. It is not appropriate for a routine, comprehensive exam unless
counseling is the primary focus.
Pertinent Positives:
Sexually active with both male and female
Inconsistent use of protection
Pertinent Negatives:
No current behavioral health concerns
No engagement in transactional sex or high risk exposure
FINAL DIAGNOSIS
Encounter for gynecological examination (general) (routine) without abnormal findings
(ICD-10: Z01.419)
Rationale: Ty is a 22-year-old nonbinary individual assigned female at birth who presents for a
routine annual physical that includes gynecological screening, notably a first-time Pap smear.
The visit is preventive in nature, with no abnormal findings reported in the review of systems or
physical exam. This diagnosis code is appropriate per ICD-10-CM guidelines when a patient
undergoes a general or routine gynecological examination, including screening procedures such
as Pap smears, without symptoms or abnormal clinical findings.
Pertinent Positives:
Sexually active with male and female partners → appropriate STI and cervical cancer screening.
First gynecologic screening, appropriate timing and preventive context. No previous Pap smear
documented, initiation of baseline screening.
LMP and menstrual history consistent with normal function
Pertinent Negatives:
Denies abnormal vaginal bleeding, discharge, or pelvic pain
No history of STIs or reproductive tract infections
No dysuria, urinary frequency, or suprapubic tenderness
No cervical or uterine tenderness, masses, or structural abnormalities
No cervical or uterine tenderness, masses, or structural abnormalities
PLAN
Labs Ordered:
Pap smear – for cervical cancer screening (per USPSTF guidelines for individuals with a cervix
starting at age 21)
STI screening labs:
Urine GC/CT NAAT – for chlamydia and gonorrhea
HIV antigen/antibody combo
RPR – for syphilis
Hepatitis B surface antigen (HBsAg)
Hepatitis C antibody
Pregnancy test (urine hCG) – precautionary due to sexual activity with male partners
MEDICATIONS AND TREATMENT:
None prescribed today.
Ty is not currently seeking contraception and is not on hormone therapy. May consider PrEP
counseling if future behavior or exposure risk increases.
REFERRALS AND FOLLOW UPS:
No specialty referral needed at this time.
Return to clinic:
Pap smear results and STI screening follow-up (2–3 weeks)
Annual Exam in 1 year
PATIENT EDUCATION:
Explained purpose and importance of Pap smear screening beginning at age 21 and continuing
every 3 years if normal
Discussed STI risks and the importance of regular screening despite absence of symptoms
Encouraged consistent barrier protection with all partners, regardless of gender
Discussed vaccine preventable STIs (Hepatitis B, HPV – already completed HPV series)
Educated on the confidentiality of reproductive and sexual health care
Reviewed signs/symptoms that warrant urgent follow-up: fever, pelvic pain, abnormal discharge,
or post-coital bleeding
Provided support for gender-affirming care and inclusive communication