Post 1
Gayle is a 25-year-old woman who comes to your office for her first Pap smearexam. She tried to have a Pap smear before, but she was unable to tolerateinsertion of the speculum. She cannot use tampons during her menses due topain at her introitus when she tries to insert the tampon. Her last boyfriend brokeup with her after 6 months because she was unable to have intercourse with himdue to pain at her introitus when trying to insert his penis. The patient cannotremember exactly when this pain started because she didn’t attempt to usetampons until she was 19 years old. She did not attempt intercourse until she was21 years old. She thinks she noticed this pain the first time she attempted toinsert a tampon but cannot be sure. She is extremely anxious and almost in tearsabout the thought of having a Pap smear, but thinks she “must” have one eventhough she reports being unable to ever have vaginal intercourse.
Subjective –
Chief Complaint (CC): Gayle presents for her first Pap smear exam. She is extremely anxious and almost in tearsabout the thought of having a Pap smear, but thinks she “must” have one eventhough she reports being unable to ever have vaginal intercourse..
History of Present Illness (HPI): Gayle reports being unable to tolerate speculum insertion during previous Pap smear attempts. She also experiences pain at her introitus when using tampons and attempting vaginal intercourse. This pain has been present since her late teens to early twenties.
Medications: None reported.
Allergies: No known drug allergies.
Last Menstrual Period (LMP): 04/03/2024
Gyn/OB History: No history of pregnancies or abortions. No history of gynecological surgeries.
Past Medical History (PMH): No significant past medical history reported. No PMHx of ovarian or breast ca.
Family History: Non-contributory to current complaint. No FMHx of ovarian or breast ca.
Social History: Single, sexually active with difficulty in vaginal intercourse, non-smoker, occasional alcohol use.
Review of Systems (ROS):
General: No weight loss, fever, or fatigue reported.
Cardiovascular: No chest pain, palpitations, or edema reported.
Respiratory: No cough, shortness of breath, or wheezing reported.
Gastrointestinal: No abdominal pain, nausea, vomiting, or changes in bowel habits reported.
Genitourinary/Gyn: Pain at introitus during attempted vaginal penetration. No abnormal vaginal discharge, itching, or lesions reported.
Breast: No breast pain, lumps, or nipple discharge reported.
Integumentary: No rashes, lesions, or skin changes reported.
I would approach Gayle with empathy and sensitivity, acknowledging her anxiety and distress about the medical examination. It’s crucial to create a safe and non-judgmental environment to encourage open communication and trust.
In addition to the information provided in the HPI, I would ask Gayle about the following relevant questions:
Can you describe the pain you experience at your introitus in more detail? (e.g., sharp, dull, burning, constant, intermittent)
Have you noticed any specific triggers or patterns related to the pain, such as during certain activities or positions?
Have you tried any methods or techniques to alleviate the pain during attempted vaginal intercourse or speculum insertion?
Do you experience any other symptoms along with the pain, such as vaginal dryness, itching, or bleeding?
C. Additional medical history questions to ask Gayle may include:
Have you ever been diagnosed with any pelvic or genital infections?
Do you have a history of any chronic pain conditions or pelvic surgeries?
Are you currently using any medications or treatments for pain management or gynecological issues?
D. In terms of social history, it’s important to delve into aspects that may impact Gayle’s overall well-being and medical care:
Are you currently in a relationship or sexually active? If so, how has the pain affected your intimate relationships?
Do you have any concerns or fears related to your sexual health or reproductive system?
Have you ever experienced any form of sexual trauma or abuse?
Are there any cultural or religious factors that influence your views on sexual health and medical care?
Objective-
General: Gayle appears anxious and distressed, with signs of emotional distress noted.
Respiratory rate: 18 breaths per minute
Temperature: 97.1
General Appearance: Anxious and tearful during the examination.
Head and Neck: Normocephalic, atraumatic. Palpated thyroid within normal limits.
Assessment and Diagnosis –
A. Detailed Focused Physical Assessment:
General Appearance: Gayle appears anxious and distressed, maintaining eye contact but exhibiting signs of emotional distress such as tearing up during the examination.
Vital Signs:
Blood Pressure: 117/24 mmHg (within normal limits)
Heart Rate: 66 beats per minute (within normal limits)
Respiratory Rate: 18 breaths per minute (within normal limits)
Temperature: 97.1 °C (oral, normal range)
Head and Neck: Normocephalic, atraumatic. Palpated thyroid is within normal limits.
Cardiovascular: Regular rate and rhythm, no murmurs or abnormal sounds appreciated on auscultation.Respiratory: Clear lung sounds bilaterally, no wheezing or crackles noted.Abdominal Examination: Non-tender, no masses or organomegaly appreciated on palpation.
Pelvic Examination: Attempted but not completed due to the patient’s inability to tolerate speculum insertion. Patient reports significant pain and discomfort during the attempted examination.
Breast Examination: No breast abnormalities, masses, or tenderness noted on examination.
Skin Examination: No rashes, lesions, or discoloration noted on the skin.
B. Pap Smear Necessity: A Pap smear may not be feasible or necessary for Gayle at this time due to her inability to tolerate speculum insertion and the significant pain and distress associated with pelvic examinations (ACOG, 2021). However, it’s important to consider alternative screening methods for cervical cancer, such as HPV testing alone or self-sampling kits, depending on the recommendations of a specialist.
C. Other Tests and Rationale:
HPV
Given Gayle’s age and the need for cervical cancer screening, HPV testing alone can be considered as an alternative to Pap smear if she cannot tolerate speculum insertion (ACOG, 2021). HPV testing can identify high-risk HPV strains that are associated with cervical cancer, guiding further management.
Presumptive Diagnosis:
A. Given Gayle’s symptoms and history, a presumptive diagnosis could be vaginismus. Vaginismus is a condition characterized by involuntary muscle spasms of the pelvic floor muscles, specifically the pubococcygeus muscle, in response to attempted vaginal penetration, leading to pain and difficulty with intercourse or pelvic examinations (Reissing et al., 2013).
B. Differential Diagnoses:
Testing:
Transvaginal Ultrasound: This can be performed to assess the pelvic organs, including the uterus, ovaries, and surrounding structures. It can help evaluate for any anatomical abnormalities, such as ovarian cysts or uterine fibroids, which may contribute to Gayle’s symptoms (Cleveland Clinic, 2022).Consultation with a Gynecologist or Sexual Pain Specialist: Referring Gayle to a specialist can provide a comprehensive evaluation of her condition, including a detailed pelvic examination under sedation if necessary (ACOG, 2021). The specialist can also assess for conditions like vaginismus, endometriosis, or pelvic floor dysfunction, and recommend appropriate management strategies, such as pelvic floor physical therapy or psychotherapy for anxiety (ACOG, 2021).
Referral to a Specialist:
Refer Gayle to a gynecologist specializing in sexual pain disorders or a sexual medicine specialist for a comprehensive evaluation and management of vaginismus (Reissing et al., 2013). This specialist can conduct a detailed pelvic examination under sedation if necessary and assess for contributing factors such as pelvic floor muscle tension, anxiety, and psychosexual issues.
Psychological Assessment and Counseling:
Education and Self-Care Strategies:
Educate Gayle about vaginismus, its causes, and treatment options (Reissing et al., 2013). Provide information on self-care strategies, such as using vaginal dilators or relaxation techniques, to gradually desensitize and stretch the pelvic floor muscles (Melnik, 2012).
Consider pharmacological options, such as topical lidocaine or muscle relaxants, under the guidance of a specialist, to manage pain and facilitate relaxation of pelvic floor muscles during therapy (Reissing et al., 2013).
Schedule regular follow-up appointments with the specialist and pelvic floor physical therapist to monitor progress, adjust treatment interventions as needed, and provide ongoing support and guidance (Melnik, 2012).
Supportive Care and Resources:
Management and Interventions:
Pelvic Floor Physical Therapy (PFPT): Refer Gayle to a pelvic floor physical therapist for relaxation exercises, biofeedback, and desensitization therapy to reduce pelvic floor muscle tension.
B. Treatment and Medication:
Muscle Relaxants: Depending on the severity of muscle spasms and under the guidance of a specialist, muscle relaxants may be prescribed to help reduce pelvic floor muscle tension.
Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) may be considered for their analgesic and anxiolytic effects, especially if Gayle experiences significant pain and anxiety (Brotto & Basson, 2014).
C. Treatment/Management Guidelines:
Pharmacological: Educate Gayle about the purpose, dosage, potential side effects, and proper application of topical lidocaine if prescribed. Discuss the role of muscle relaxants or antidepressants, if prescribed, in managing pelvic floor muscle tension and anxiety.
Non-Pharmacological: Provide detailed instructions on pelvic floor relaxation exercises, use of vaginal dilators, and relaxation techniques to practice at home. Discuss the importance of communication with her healthcare team and adherence to treatment plans.
E. Follow-Up
Plan:
Schedule regular follow-up appointments with the specialist, pelvic floor physical therapist, and psychological counselor to monitor progress, adjust treatment interventions, and provide ongoing support.
Reassess Gayle’s symptoms, functional status, and quality of life at follow-up visits to ensure treatment effectiveness and address any emerging concerns or challenges.
Scenario:
Subjective:
22-year-old female, individual who identifies as They/Them.
– CC: Ty presents for an annual physical exam.
What name would you like to be called?
Can you confirm your legal name for our records?
What pronouns do you prefer for others to use when referring to you?
Any current symptoms or concerns related to your physical and mental health?
Any family history of significant medical conditions.
what is your sexual history, including your partners’ genders and safer sex practices?
-A detailed focused physical assessment would include vital signs, general appearance, cardiovascular, respiratory, abdominal, musculoskeletal, and neurological examinations.
-Family History:
– Ty reports a family history of hypertension on their mother’s side. No other significant family medical history noted.
– Exercise: 5 times a week
– Substance use: Denies alcohol and substance use
– Constitutional: No fever, chills, or weight changes reported.
– Cardiovascular: No chest pain, palpitations, or edema.
– Genitourinary: No urinary symptoms or changes in bladder habits.
– Musculoskeletal: No joint pain, stiffness, or swelling.
Objective:
– Vitals:
BP 120/83
HR 65
RR 18
SpO2 98%
weight 128 lb
Height 5’1″
Temp 98.4°F
– Physical Findings:
General appearance is consistent with stated age and gender identity. No acute distress observed. Cardiovascular, respiratory, abdominal, musculoskeletal, and neurological exams within normal limits.
Assessment/Diagnosis:
Presumptive Diagnosis:
Gender dysphoria (ICD-10 code: F64.9)
Other specified counseling (ICD-10 Code: Z71.89)
The presumptive diagnosis of gender dysphoria is made based on the patient’s history of being assigned female at birth but identifying as They/Them, indicating a misalignment between their assigned gender and experienced gender identity. The patient’s selection of both “have sex with females” and “have sex with males” in the sexual history further supports their gender identity as non-binary or genderqueer. Gender dysphoria involves distress or discomfort caused by this incongruence between one’s assigned gender and experienced gender identity, and it aligns with the patient’s presentation and self-identification. However, a formal diagnosis would require further assessment and evaluation by a qualified healthcare provider.
Working Diagnosis:
Anxiety disorder (F41.9): Anxiety symptoms may be present due to societal pressures or personal concerns related to gender identity.
Adjustment disorder (F43.20): The patient may be experiencing difficulty adjusting to their gender identity or societal expectations.
– POCT:
Hormone Levels: Measurement of serum levels of testosterone and estrogen can help monitor hormone levels and adjust hormone therapy doses as needed to achieve desired physical changes while minimizing side effects.
Lipid Profile: Monitoring lipid levels, including cholesterol and triglycerides, is important for assessing cardiovascular risk, as hormone therapy may affect lipid metabolism.
Liver Function Tests: Regular monitoring of liver function, ALT, AST, is recommended due to potential hepatotoxicity associated with hormone therapy, particularly with certain formulations or routes of administration.
CBC: Assessing hemoglobin and hematocrit levels can help monitor for potential side effects such as polycythemia, which may occur with testosterone therapy.
– Diagnosis: Routine physical exam.
Plan:
– Treatment:
Treatment for gender dysphoria varies based on individual needs and preferences. It typically involves a multidisciplinary approach, which may include psychotherapy, hormone therapy, and surgical interventions. In the case of Ty, as they identify as non-binary or genderqueer, their treatment plan would be personalized to address their specific goals and needs.
Psychotherapy:Counseling or therapy can provide support, guidance, and coping strategies for managing gender dysphoria-related distress. It can also assist with exploring gender identity, navigating social and familial relationships, and developing resilience.
Hormone Therapy: For individuals seeking hormone therapy, testosterone or estrogen may be prescribed to help align secondary sex characteristics with their gender identity. However, it’s essential to discuss the risks, benefits, and potential side effects of hormone therapy with the patient, including the impact on fertility, cardiovascular health, and emotional well-being.
Surgical Interventions: Some individuals may pursue surgical interventions, such as chest reconstruction or genital surgery, to further align their physical appearance with their gender identity. These procedures carry risks, including complications from surgery, changes in sensation, and potential psychological adjustments.
Social Support: Building a supportive network of friends, family, and community resources can be invaluable for individuals navigating gender identity concerns. Support groups, online communities, and advocacy organizations can provide validation, connection, and resources for affirming gender identity.
Possible birth control and safe sex methods.
– Patient Education:
Provided education on maintaining overall health and well-being, including recommendations for diet, exercise, and regular health screenings.
Educated patient having a male partner about safe sex practices, contraception, and regular STI screenings.
Educated patient having a female partner may include discussions about reproductive health, safe sex practices, and accessing appropriate healthcare services.
Provide education about the concept of gender identity and affirm the validity of Ty’s non-binary or genderqueer identity. Offer resources and support for exploring and expressing their gender identity authentically.
If interest in hormone therapy, educate them about the effects of testosterone or estrogen on their body, including changes in secondary sex characteristics, mood, and libido. Discuss the process of hormone therapy, including dosages, administration methods, and monitoring.
If considering surgical interventions, provide detailed information about the procedures, potential outcomes, risks, and recovery process. Offer resources for finding qualified surgeons and support groups for individuals undergoing gender-affirming surgeries.
Emphasize the importance of prioritizing mental health and self-care, including seeking support from mental health professionals, engaging in self-compassion practices, and accessing support groups or online communities for individuals with similar experiences.
Encourage Ty to build a supportive network of friends, family, and community resources that affirm their gender identity and provide validation and understanding.
– Referral: mental health professionals and endocrinologists, to ensure coordinated and comprehensive care for Ty’s gender dysphoria.
Follow-up:
Follow up in 1 month to address any concerns or side effects related to hormone therapy or other treatments and adjust the treatment plan as needed.
– Health Maintenance:
Pap screenings
Cervical cancer screening
Regular pelvic exams
Schedule annual gynecological visits for ongoing vaginal health monitoring
BRCA related cancer screening
Depression and suicide screening for adults
Hypertension in Adults
Anxiety Disorders in Adults
STD screening
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