Assignment Prompt & Instructions
see attachment
– ## Week6Response1.pdf
**## Week6Response1.pdf**
Case Scenario 1: Gynecologic Conditions Chart
Diagn
osis Definition Presentation / Signs
and Symptoms Management
Barth
olin
Cyst
Obstruction of the
Bartholin duct
causing fluid
buildup, forming a
cyst in the labia
majora.
Unilateral, painless
labial swelling near
vaginal introitus. Can
become tender and
erythematous if
infected.
Warm compresses or sitz
baths; if symptomatic or
recurrent: incision and
drainage, Word catheter, or
marsupialization. Antibiotics if
abscessed.
Squa
mous
Carci
noma
of the
Vagin
a
A rare primary
cancer arising from
the squamous
epithelium of the
vaginal mucosa.
Vaginal bleeding,
discharge, palpable
vaginal mass, or pain,
often postmenopausal.
Diagnosis via biopsy.
Management includes surgical
resection, radiation therapy,
and/or chemotherapy based on
staging. Referral to
gynecologic oncology.
Aden
ocarc
inom
a of
the
Vagin
a
Malignant glandular
tumor of the vagina,
often associated
with in-utero
diethylstilbestrol
(DES) exposure.
Vaginal spotting,
watery discharge, or
mass, especially in
young women with
DES history.
Biopsy confirms diagnosis.
Treated with surgery and/or
radiation. DES-exposed
women require lifelong
surveillance.
Liche
n
Scler
osus
Chronic, progressive
inflammatory
dermatosis affecting
vulvar and perianal
skin, mostly in
postmenopausal
women.
Intense pruritus,
burning, dyspareunia,
thin white plaques
("cigarette paper"
appearance), and skin
fragility. Risk of vulvar
SCC.
High-potency topical
corticosteroids (e.g., clobetasol
0.05%), emollients, regular
follow-up. Biopsy if suspicious
for malignancy.
Liche
n
Planu
s
Inflammatory
autoimmune
condition involving
skin and mucosal
surfaces including
the vulva and
vagina.
Painful erosions, white
lacy striae (Wickham’s
striae), vaginal
discharge,
dyspareunia, possible
scarring.
Topical corticosteroids or
calcineurin inhibitors; manage
pain; treat secondary
infections; possible systemic
immunosuppressants for
severe cases.
SOAP Note
Patient: Kelly
Age: 19
Gender: Female
SUBJECTIVE
Chief Complaint (CC): "Severe menstrual pain."
History of Present Illness (HPI):
Kelly is a 19-year-old G0P0 female who presents to the clinic today with a chief complaint of
severe, cyclical pelvic pain that has been present since menarche (age 13) but has progressively
worsened over the last 2-3 years. The pain is described as a "deep, cramping, and sometimes
sharp" pain located in the suprapubic area, radiating to her lower back and anterior thighs. The
pain typically begins 1-2 days prior to the onset of her menses and is most severe during the first
48 hours of her period. She rates the pain as 9-10/10 at its worst, improving to a 3-4/10 after day
3 of her cycle. The pain is debilitating, causing her to miss work at her part-time job 1-2 days
each month. She reports at least one episode of fainting (syncope) from the severity of the pain
during her last cycle.
• Associated Symptoms:
o Gastrointestinal: She experiences severe pain with defecation (dyschezia), particularly
during her menses. This leads her to avoid bowel movements, resulting in secondary
constipation. She denies any blood in the stool. She also reports bloating and occasional
nausea during her periods.
Liche
n
Simpl
ex
Chro
nicus
Secondary skin
thickening from
chronic scratching or
irritation of the vulva.
Thickened, leathery
skin, usually unilateral.
Intense itching, worse
at night.
Discontinue irritants, use high-
potency topical corticosteroids,
antihistamines, barrier creams.
Address underlying cause
(e.g., infection, stress).
Vulvo
dynia
Chronic vulvar pain
without identifiable
cause, lasting >3
months.
Burning, stinging,
irritation, especially
with touch or
intercourse. Often no
visible abnormalities.
Multidisciplinary approach:
pelvic floor physical therapy,
topical lidocaine, low-dose
antidepressants (TCAs or
SNRIs), cognitive behavioral
therapy, avoidance of irritants.
o Gynecologic: Her menses are heavy (menorrhagia), requiring her to change a super-
absorbency tampon or pad every 1-2 hours for the first two days. Her periods last for a total
of 7 days, with a gradual tapering of flow. She reports occasional deep dyspareunia (pain
with deep intercourse). She denies any intermenstrual bleeding or postcoital spotting. No
abnormal vaginal discharge, odor, or itching.
• Palliating/Provoking Factors: Pain is provoked by menstruation and defecation. She has
tried over-the-counter Ibuprofen (400 mg) and Acetaminophen (500 mg) with minimal to no
relief. Heating pads provide mild, temporary relief.
• Pertinent Negatives: Denies fever, chills, urinary symptoms (dysuria, frequency, urgency),
or changes in appetite outside of her menses.
Menstrual History:
• Menarche: Age 13
• Cycle: Regular, q28-30 days
• Duration: 7 days
• Flow: Heavy for 2 days, then moderate to light for 5 days.
Gynecologic/Obstetric History:
• Gravida/Para: G0P0
• Sexual Activity: Sexually active with one male partner for the last year.
• Contraception: Reports inconsistent condom use. Has never used hormonal contraception.
• STI History: Denies any known history of STIs. Has never been screened.
• Pap Smear: None to date (age-appropriate).
Past Medical History (PMH): None. No chronic illnesses.
Past Surgical History (PSH): None.
Medications: Ibuprofen 400 mg PRN for pain, Acetaminophen 500 mg PRN for pain.
Allergies: No Known Drug Allergies (NKDA).
Family History: Mother has a history of "bad periods" and heavy bleeding but no formal
diagnosis. No known family history of gynecologic cancers, endometriosis, or bleeding
disorders.
Social History: College student, works part-time. Denies tobacco use. Reports occasional social
alcohol use (2-3 drinks per weekend). Denies illicit drug use. Reports significant stress related to
her symptoms and their impact on her work and daily life.
OBJECTIVE
Vitals:
• BP: 118/72 mmHg
• HR: 74 bpm
• RR: 16 rpm
• Temp: 98.6°F (37.0°C)
• SpO2: 99% on room air
• BMI: 23.9 kg/m ²
General: Patient is a well-developed, well-nourished female in no acute distress. She is alert,
oriented, and cooperative.
Physical Exam:
• Abdomen: Soft, non-distended. Normoactive bowel sounds in all four quadrants. Mild
suprapubic tenderness to deep palpation. No guarding, rebound tenderness, or organomegaly
noted.
• Pelvic Exam:
o External Genitalia: Normal external female genitalia. No lesions, erythema, or swelling.
o Speculum: Vaginal vault is pink and without lesions. Cervix is nulliparous, pink, with no
discharge, friability, or visible lesions. A small amount of old, brown blood is noted in the
posterior fornix, consistent with recent menses.
o Bimanual: Uterus is of normal size, retroverted, and has limited mobility. There is
significant tenderness with uterine motion (positive cervical motion tenderness). Palpation of
the posterior cul-de-sac and uterosacral ligaments elicits exquisite tenderness. Adnexa are
tender to palpation, left more so than right, without distinct masses appreciated.
In-Office test:
• Urine hCG (Pregnancy Test): Negative
ASSESSMENT
1. Endometriosis, Suspected (N80.9): This is the leading diagnosis given the constellation of
classic symptoms: severe, progressive dysmenorrhea since menarche, deep dyspareunia, and
cyclical dyschezia. The physical exam findings of a fixed, retroverted uterus and marked
tenderness of the uterosacral ligaments strongly support this diagnosis. The syncopal episode
highlights the severity of the pain.
2. Menorrhagia (Heavy Menstrual Bleeding, N92.0): Patient's report of soaking pads/
tampons every 1-2 hours for two days meets the clinical definition. This is likely secondary
to underlying pathology such as endometriosis or adenomyosis.
3. Dysmenorrhea, Secondary (N94.5): The patient’s severe menstrual pain, associated with
other symptoms and physical findings, is indicative of a secondary cause rather than primary
(physiologic) dysmenorrhea.
4. Constipation (K59.00): Secondary to pain avoidance with defecation (dyschezia) during
menses.
5. Contraception Counseling / Health Maintenance (Z30.011): Patient is sexually active
with inconsistent barrier method use, placing her at risk for unintended pregnancy and STIs.
Differential Diagnoses:
• Adenomyosis: Overlaps significantly with endometriosis symptoms (menorrhagia,
dysmenorrhea). It is less common in this age group but remains a strong possibility.
Ultrasound may provide clues.
• Primary Dysmenorrhea: Unlikely given the severity, focal tenderness on exam, and
associated GI symptoms.
• Pelvic Inflammatory Disease (PID): Less likely given the cyclical nature of the pain, lack
of fever, and absence of purulent cervical discharge. However, chronic PID can cause
adhesions and pain, so STI screening is warranted.
• Uterine Fibroids (Leiomyoma): Can cause heavy bleeding and pain, but less likely to cause
the specific dyschezia and uterosacral tenderness seen here. Less common in a 19-year-old.
PLAN
1. Diagnostics:
a. Pelvic Ultrasound (Transvaginal & Abdominal): Ordered to evaluate for structural
abnormalities, specifically looking for endometriomas ("chocolate cysts"), signs of
adenomyosis, uterine fibroids, and to assess uterine mobility/potential adhesions.
b. Labs: CBC to assess for anemia from menorrhagia. Gonorrhea/Chlamydia NAA (urine or
swab) to screen for STIs.
c. Symptom Diary: Patient provided with a diary to track pain levels, bleeding, bowel
symptoms, and medication use in relation to her menstrual cycle.
2. Therapeutics (Empiric Treatment):
a. Pain/Inflammation: Discontinue PRN OTC use. Prescribed Naproxen 550 mg, 1 tablet by
mouth twice daily with food, to be started 2 days before expected onset of menses and
continued through the first 3 days of bleeding.
b. Hormonal Suppression: Initiated treatment with a continuous combined oral contraceptive
(COC).
i. Rx: [e.g., Drospirenone/Ethinyl Estradiol 3mg/0.02mg], 1 tablet by mouth daily.
ii. Instructions: Instructed patient to take pills continuously, skipping the placebo week, to
induce amenorrhea. Explained that this is the first-line treatment for suspected endometriosis
to suppress endometrial tissue growth, reduce bleeding, and alleviate pain. Discussed risks,
benefits, and common side effects (e.g., breakthrough bleeding initially).
3. Patient Education:
a. Diagnosis: Discussed the suspected diagnosis of endometriosis in detail, explaining that it is
a condition where uterine lining-like tissue grows outside the uterus, causing inflammation
and pain.
b. Treatment Goal: Explained that the goal of the current plan is to manage symptoms, reduce
pain to a tolerable level, control bleeding, and allow her to maintain normal daily activities.
c. Constipation: Advised increasing fluid and dietary fiber intake. Suggested Miralax or
docusate sodium PRN if constipation persists despite pain control.
d. Non-pharmacologic: Encouraged continued use of heating pads. Advised light exercise like
walking or stretching as tolerated.
e. Red Flags: Instructed to call or return if she experiences pain unresponsive to the new
medication regimen, fever >100.4°F, or menstrual bleeding that soaks through a pad/tampon
every hour for more than two consecutive hours.
4. Health Maintenance:
a. Counseled on safe sex practices and the importance of consistent condom use for STI
prevention, even while on OCPs.
5. Follow-up:
a. Will call the patient with lab and ultrasound results within one week.
b. Schedule a follow-up appointment in 3 months to evaluate her response to the empiric
treatment regimen.
c. If symptoms are not significantly improved, a referral to a Gynecologist for further
evaluation and consideration of diagnostic laparoscopy (the gold standard for diagnosis) will
be made.
– Case Scenario 1: Gynecologic Conditions Chart
– SOAP Note
**## Week6Response1.pdf**
Case Scenario 1: Gynecologic Conditions Chart
Diagn
osis Definition Presentation / Signs
and Symptoms Management
Barth
olin
Cyst
Obstruction of the
Bartholin duct
causing fluid
buildup, forming a
cyst in the labia
majora.
Unilateral, painless
labial swelling near
vaginal introitus. Can
become tender and
erythematous if
infected.
Warm compresses or sitz
baths; if symptomatic or
recurrent: incision and
drainage, Word catheter, or
marsupialization. Antibiotics if
abscessed.
Squa
mous
Carci
noma
of the
Vagin
a
A rare primary
cancer arising from
the squamous
epithelium of the
vaginal mucosa.
Vaginal bleeding,
discharge, palpable
vaginal mass, or pain,
often postmenopausal.
Diagnosis via biopsy.
Management includes surgical
resection, radiation therapy,
and/or chemotherapy based on
staging. Referral to
gynecologic oncology.
Aden
ocarc
inom
a of
the
Vagin
a
Malignant glandular
tumor of the vagina,
often associated
with in-utero
diethylstilbestrol
(DES) exposure.
Vaginal spotting,
watery discharge, or
mass, especially in
young women with
DES history.
Biopsy confirms diagnosis.
Treated with surgery and/or
radiation. DES-exposed
women require lifelong
surveillance.
Liche
n
Scler
osus
Chronic, progressive
inflammatory
dermatosis affecting
vulvar and perianal
skin, mostly in
postmenopausal
women.
Intense pruritus,
burning, dyspareunia,
thin white plaques
("cigarette paper"
appearance), and skin
fragility. Risk of vulvar
SCC.
High-potency topical
corticosteroids (e.g., clobetasol
0.05%), emollients, regular
follow-up. Biopsy if suspicious
for malignancy.
Liche
n
Planu
s
Inflammatory
autoimmune
condition involving
skin and mucosal
surfaces including
the vulva and
vagina.
Painful erosions, white
lacy striae (Wickham’s
striae), vaginal
discharge,
dyspareunia, possible
scarring.
Topical corticosteroids or
calcineurin inhibitors; manage
pain; treat secondary
infections; possible systemic
immunosuppressants for
severe cases.
SOAP Note
Patient: Kelly
Age: 19
Gender: Female
SUBJECTIVE
Chief Complaint (CC): "Severe menstrual pain."
History of Present Illness (HPI):
Kelly is a 19-year-old G0P0 female who presents to the clinic today with a chief complaint of
severe, cyclical pelvic pain that has been present since menarche (age 13) but has progressively
worsened over the last 2-3 years. The pain is described as a "deep, cramping, and sometimes
sharp" pain located in the suprapubic area, radiating to her lower back and anterior thighs. The
pain typically begins 1-2 days prior to the onset of her menses and is most severe during the first
48 hours of her period. She rates the pain as 9-10/10 at its worst, improving to a 3-4/10 after day
3 of her cycle. The pain is debilitating, causing her to miss work at her part-time job 1-2 days
each month. She reports at least one episode of fainting (syncope) from the severity of the pain
during her last cycle.
• Associated Symptoms:
o Gastrointestinal: She experiences severe pain with defecation (dyschezia), particularly
during her menses. This leads her to avoid bowel movements, resulting in secondary
constipation. She denies any blood in the stool. She also reports bloating and occasional
nausea during her periods.
Liche
n
Simpl
ex
Chro
nicus
Secondary skin
thickening from
chronic scratching or
irritation of the vulva.
Thickened, leathery
skin, usually unilateral.
Intense itching, worse
at night.
Discontinue irritants, use high-
potency topical corticosteroids,
antihistamines, barrier creams.
Address underlying cause
(e.g., infection, stress).
Vulvo
dynia
Chronic vulvar pain
without identifiable
cause, lasting >3
months.
Burning, stinging,
irritation, especially
with touch or
intercourse. Often no
visible abnormalities.
Multidisciplinary approach:
pelvic floor physical therapy,
topical lidocaine, low-dose
antidepressants (TCAs or
SNRIs), cognitive behavioral
therapy, avoidance of irritants.
o Gynecologic: Her menses are heavy (menorrhagia), requiring her to change a super-
absorbency tampon or pad every 1-2 hours for the first two days. Her periods last for a total
of 7 days, with a gradual tapering of flow. She reports occasional deep dyspareunia (pain
with deep intercourse). She denies any intermenstrual bleeding or postcoital spotting. No
abnormal vaginal discharge, odor, or itching.
• Palliating/Provoking Factors: Pain is provoked by menstruation and defecation. She has
tried over-the-counter Ibuprofen (400 mg) and Acetaminophen (500 mg) with minimal to no
relief. Heating pads provide mild, temporary relief.
• Pertinent Negatives: Denies fever, chills, urinary symptoms (dysuria, frequency, urgency),
or changes in appetite outside of her menses.
Menstrual History:
• Menarche: Age 13
• Cycle: Regular, q28-30 days
• Duration: 7 days
• Flow: Heavy for 2 days, then moderate to light for 5 days.
Gynecologic/Obstetric History:
• Gravida/Para: G0P0
• Sexual Activity: Sexually active with one male partner for the last year.
• Contraception: Reports inconsistent condom use. Has never used hormonal contraception.
• STI History: Denies any known history of STIs. Has never been screened.
• Pap Smear: None to date (age-appropriate).
Past Medical History (PMH): None. No chronic illnesses.
Past Surgical History (PSH): None.
Medications: Ibuprofen 400 mg PRN for pain, Acetaminophen 500 mg PRN for pain.
Allergies: No Known Drug Allergies (NKDA).
Family History: Mother has a history of "bad periods" and heavy bleeding but no formal
diagnosis. No known family history of gynecologic cancers, endometriosis, or bleeding
disorders.
Social History: College student, works part-time. Denies tobacco use. Reports occasional social
alcohol use (2-3 drinks per weekend). Denies illicit drug use. Reports significant stress related to
her symptoms and their impact on her work and daily life.
OBJECTIVE
Vitals:
• BP: 118/72 mmHg
• HR: 74 bpm
• RR: 16 rpm
• Temp: 98.6°F (37.0°C)
• SpO2: 99% on room air
• BMI: 23.9 kg/m ²
General: Patient is a well-developed, well-nourished female in no acute distress. She is alert,
oriented, and cooperative.
Physical Exam:
• Abdomen: Soft, non-distended. Normoactive bowel sounds in all four quadrants. Mild
suprapubic tenderness to deep palpation. No guarding, rebound tenderness, or organomegaly
noted.
• Pelvic Exam:
o External Genitalia: Normal external female genitalia. No lesions, erythema, or swelling.
o Speculum: Vaginal vault is pink and without lesions. Cervix is nulliparous, pink, with no
discharge, friability, or visible lesions. A small amount of old, brown blood is noted in the
posterior fornix, consistent with recent menses.
o Bimanual: Uterus is of normal size, retroverted, and has limited mobility. There is
significant tenderness with uterine motion (positive cervical motion tenderness). Palpation of
the posterior cul-de-sac and uterosacral ligaments elicits exquisite tenderness. Adnexa are
tender to palpation, left more so than right, without distinct masses appreciated.
In-Office test:
• Urine hCG (Pregnancy Test): Negative
ASSESSMENT
1. Endometriosis, Suspected (N80.9): This is the leading diagnosis given the constellation of
classic symptoms: severe, progressive dysmenorrhea since menarche, deep dyspareunia, and
cyclical dyschezia. The physical exam findings of a fixed, retroverted uterus and marked
tenderness of the uterosacral ligaments strongly support this diagnosis. The syncopal episode
highlights the severity of the pain.
2. Menorrhagia (Heavy Menstrual Bleeding, N92.0): Patient's report of soaking pads/
tampons every 1-2 hours for two days meets the clinical definition. This is likely secondary
to underlying pathology such as endometriosis or adenomyosis.
3. Dysmenorrhea, Secondary (N94.5): The patient’s severe menstrual pain, associated with
other symptoms and physical findings, is indicative of a secondary cause rather than primary
(physiologic) dysmenorrhea.
4. Constipation (K59.00): Secondary to pain avoidance with defecation (dyschezia) during
menses.
5. Contraception Counseling / Health Maintenance (Z30.011): Patient is sexually active
with inconsistent barrier method use, placing her at risk for unintended pregnancy and STIs.
Differential Diagnoses:
• Adenomyosis: Overlaps significantly with endometriosis symptoms (menorrhagia,
dysmenorrhea). It is less common in this age group but remains a strong possibility.
Ultrasound may provide clues.
• Primary Dysmenorrhea: Unlikely given the severity, focal tenderness on exam, and
associated GI symptoms.
• Pelvic Inflammatory Disease (PID): Less likely given the cyclical nature of the pain, lack
of fever, and absence of purulent cervical discharge. However, chronic PID can cause
adhesions and pain, so STI screening is warranted.
• Uterine Fibroids (Leiomyoma): Can cause heavy bleeding and pain, but less likely to cause
the specific dyschezia and uterosacral tenderness seen here. Less common in a 19-year-old.
PLAN
1. Diagnostics:
a. Pelvic Ultrasound (Transvaginal & Abdominal): Ordered to evaluate for structural
abnormalities, specifically looking for endometriomas ("chocolate cysts"), signs of
adenomyosis, uterine fibroids, and to assess uterine mobility/potential adhesions.
b. Labs: CBC to assess for anemia from menorrhagia. Gonorrhea/Chlamydia NAA (urine or
swab) to screen for STIs.
c. Symptom Diary: Patient provided with a diary to track pain levels, bleeding, bowel
symptoms, and medication use in relation to her menstrual cycle.
2. Therapeutics (Empiric Treatment):
a. Pain/Inflammation: Discontinue PRN OTC use. Prescribed Naproxen 550 mg, 1 tablet by
mouth twice daily with food, to be started 2 days before expected onset of menses and
continued through the first 3 days of bleeding.
b. Hormonal Suppression: Initiated treatment with a continuous combined oral contraceptive
(COC).
i. Rx: [e.g., Drospirenone/Ethinyl Estradiol 3mg/0.02mg], 1 tablet by mouth daily.
ii. Instructions: Instructed patient to take pills continuously, skipping the placebo week, to
induce amenorrhea. Explained that this is the first-line treatment for suspected endometriosis
to suppress endometrial tissue growth, reduce bleeding, and alleviate pain. Discussed risks,
benefits, and common side effects (e.g., breakthrough bleeding initially).
3. Patient Education:
a. Diagnosis: Discussed the suspected diagnosis of endometriosis in detail, explaining that it is
a condition where uterine lining-like tissue grows outside the uterus, causing inflammation
and pain.
b. Treatment Goal: Explained that the goal of the current plan is to manage symptoms, reduce
pain to a tolerable level, control bleeding, and allow her to maintain normal daily activities.
c. Constipation: Advised increasing fluid and dietary fiber intake. Suggested Miralax or
docusate sodium PRN if constipation persists despite pain control.
d. Non-pharmacologic: Encouraged continued use of heating pads. Advised light exercise like
walking or stretching as tolerated.
e. Red Flags: Instructed to call or return if she experiences pain unresponsive to the new
medication regimen, fever >100.4°F, or menstrual bleeding that soaks through a pad/tampon
every hour for more than two consecutive hours.
4. Health Maintenance:
a. Counseled on safe sex practices and the importance of consistent condom use for STI
prevention, even while on OCPs.
5. Follow-up:
a. Will call the patient with lab and ultrasound results within one week.
b. Schedule a follow-up appointment in 3 months to evaluate her response to the empiric
treatment regimen.
c. If symptoms are not significantly improved, a referral to a Gynecologist for further
evaluation and consideration of diagnostic laparoscopy (the gold standard for diagnosis) will
be made.
– Case Scenario 1: Gynecologic Conditions Chart
– SOAP Note