Bleeding After Intercourse Essay Discussion Paper
This is a continuation of order ID# 248493. Reply to peer’s post: 1 to 2 paragraphs per pear response.
Note: Responses are directed to the peer, they are at a critical level means discussing things such as your opinion of the point mentioned, why you hold that opinion, what you see wrong with the point mentioned, how you see the point consistent/inconsistent with what you have learned so far, implications for the future, consistencies/inconsistencies within the article or reading itself, and so forth. Expand on their explanation and provide an example that supports their explanation or respectfully challenging their explanation and providing an example.
Cite your reference(s) using APA 7 format.
– Responses are supported with at least 2 scholarly source per response Bleeding After Intercourse Essay Discussion Paper
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Jamelia L’s Post:
Colleagues, for this discussion I have posted a focus soap note, differential and primary diagnoses. I have also included my rationale for why I believe that the assigned case study patient has presumed diagnosis. Additionally, I have included some health history questions that I felt were imperative to making a diagnosis, but the previous examiner did not include. Finally, you will find a list of tests that I would have ordered and my reflection. I apologize for how lengthy it is, it’s a lot of information. I am very interested in your feedback. Thank you!
Episodic/Focused SOAP Note
Patient Information: SL, 24-year-old, Female, Caucasian
S.
CC (chief complaint): “Bleeding after intercourse.”
HPI: 24-year-old Caucasian female c/o vaginal bleeding with onset 6 weeks ago. Pt has not characterized the bleeding other than to say “some” as the amount. She reports associated symptoms of fever and sore throat X3weeks that was relieved by Tylenol. Timing of vaginal bleeding is after sex. Nothing is reported to make bleeding better or worse. Severity was not provided by the case study.
Current Medications:
- Midol OTC 500 mg PRN for menstrual cramps
- Tylenol OTC 650 mg PRN for fevers
Allergies: PT denies allergies to medications, latex, and environment.
PMHx: Pt reports history of menstrual cramps. She denies any prior illnesses, surgeries, and hospitalizations.
Social & Substance Hx: SL’s occupation is not given. Pt affirms smoking ½ pack of cigarettes since age 14. On weekends she drinks 6-8 glasses of hard liquor per day and smokes unquantified amount of marijuana. She reports using her seatbelt when in the car and occasionally use of sunscreen. For exercise, she jogs 3-4 times per week. Bleeding After Intercourse Essay Discussion Paper
Fam Hx: Family history is noncontributory.
Surgical Hx: Pt denies prior surgeries.
Mental Hx: Pt does not affirm prior mental health problems.
Violence Hx: No concerns or history reported.
Reproductive Hx: Menses onset at age 13, occurring every 28-32 days, and lasting for 4-6 days. Pt uses 3 tampons and takes OTC Midol for cramps. (LMP, pregnancy history, contraceptive use, gender sexual preferences and intercourse type not reported.)
ROS:
GENERAL: Pt does not report weight loss, weakness, or fatigue. Pt affirms recent fever that lasted a day or two and was relieved by OTC Tylenol.
HEENT: Pt affirms sore throat X3 weeks.
CARDIOVASCULAR: PT denies chest pain and discomfort.
RESPIRATORY: Pt denies SOB.
HEMATOLOGIC: Reports vaginal bleeding X6 weeks after sex.
LYMPHATICS: Pt does not report enlargement of lymph nodes.
GENITOURINARY/REPRODUCTIVE: Pt is sexually active and affirms bleeding post-sex. Pt does not report pain, discharge, or provide LMP.
ALLERGIES: Pt denies allergies to medication, latex, and environment.
O.
Physical exam:
Vital Signs: Height 5’ 6”, Weight 118 lbs., BMI 19.04, HR 68, BP 112/64, temperature 97.8F.
HEENT: Erythematous throat and bilateral anterior cervical adenopathy.
Lungs: Clear to auscultation.
CV: Regular rate and rhythm. No murmurs, gallops, or click auscultated.
ABD: The abdomen is soft, flat, and nontender without hepatosplenomegaly.
VVBSU: Mild frothy yellow discharge near cervix, clitoral piercing also observed.
Cervix: Observed to be friable, mild petechia. Negative for cervical motion tenderness.
Uterus: midline mobile and nontender.
Adnexa: no masses or tenderness was palpated.
Perineum/Rectum: no discharge, bumps, bruising, or abrasions observed.
Diagnostic results:
Pelvic exam showed slightly frothy yellow discharge to VVBSU. Cervix was friable with some petechia, without cervical motion tenderness. (No other diagnostic results were provided by SL’s examiner.)
A.
Primary and Differential Diagnoses:
- Trichomoniasis – This infection is caused by a protozoan that is passed during sexual intercourse. Some symptoms may include a foul-smelling vaginal discharge that may be yellow or green in color and frothy (Schumann &, Plasner, 2022). Additionally, the patient may present with dysuria, vulvar itching and erythema. SL does present with the characteristic sign of frothy yellow discharge near the cervix. She also has a friable cervix with mild petechia; this student interpreted this finding as a strawberry cervix. For the aforementioned reason, a diagnosis of trichomoniasis was made. To confirm a NAAT test should be performed as it has a remarkable sensitivity and specificity rate of greater than 90% (Schumann &, Plasner, 2022). Bleeding After Intercourse Essay Discussion Paper
- Cervicitis – Cervicitis is an inflammation of the cervix that may be caused by infectious and noninfectious etiology. Symptoms may be silent or vague, but some report bleeding after sex, such as SL’s complaint and vaginal discharge (Iqbal & Wills, 2022). In addition, physical exam may show a friable cervix, which was annotated by SL’s examiner. This condition had to be considered as SL does present with post-coital bleeding and she had discharge on pelvic exam. Cervicitis was ruled out due to the discharge being frothy and having mild petechia. This student notes that it is possible to have both trichomoniasis and cervicitis.
- Chlamydia – It is a bacterial STI caused by Chlamydia trachomatis. Symptoms may include vaginal discharge, bleeding after sex, and dysuria, but frequently people are asymptomatic. In this case study there is no data supporting the patient having abdominal pain or dysuria. However, this disease must be considered as it is responsible for the greatest number of sexually transmitted infections in the world (Mohseni et al., 2022). As such, this disease should be tested for at well-woman exams (Lockwood, 2019). NAAT testing is the Gold standard when ruling in/out gonorrhea and chlamydia (Schumann &, Plasner, 2022). It should be treated as it can cause blindness, ectopic pregnancy, infertility, and illness to newborns.
Primary Diagnosis/Presumptive Diagnosis: Vaginal Trichomoniasis
Diagnostics:
- Pelvic exam/Pap smear
- Urinalysis
- Wet prep
- GC Chlamydia
- Rapid strep
- Throat swab (GC & Chlamydia)
Treatment: If NAAT is positive the pt will be treated with a single dose of metronidazole 2 Grams. Pt to utilize salt water gargles and OTC lozenges for throat pain/discomfort as needed.
Education: Safe sex and birth control. Pre-pregnancy counseling. Avoid sex for 7 days after starting therapy. Partners should be tested and treated.
Disposition: Patient discharged home with educational resources on STI’s, safe sex, and birth control. Retest for trichomanias within 3 months of therapy. Pt to schedule Pap smear every 3 years.
Follow-up: Schedule 72 hour virtual follow up to talk about results of testing. Return to clinic for worsening symptoms to include pain 7/10 or greater, thereafter.
Referrals: None at this time. If symptoms persist, GYN for colposcopy and possible biopsy.
Reflection
This student does not agree with the Preceptor’s treatment of the patient as she left out valuable information from the PMH and PHI. SL presented with both vaginal and oral symptoms, but it is unclear if she participates in oral sex. In addition, the examiner did not state which type of vaginal sex the patient is having, or with whom (gender). Is the patient using sex toys or having rough sex? Do gynecological diseases or cancers run in the family? Simply stating that the family history was noncontributory does not create a clear picture for this student. There are so many questions that needed to be asked. Changes to the interview and documentation need to be made.
This student would have included correct documentation of vital signs. Fahrenheit was left off the temperature and no oxygenation was reported. Also, her immunization status was not reported (has she been vaccinated against HPV?). Also, the term ‘WNL” should be avoided because it does not add value to the exam or history. Finally, job history is relevant here, is the patient a sex worker? Is she promiscuous? Bleeding After Intercourse Essay Discussion Paper
This case taught the student to be thorough with the patient interview. Missing information could lead to a misdiagnosis or missed diagnosis. The student would ask the following questions to formulate differential and primary diagnoses:
Additional History Questions
- What is your gender identity?
- What’s your sexual orientation?
- Relationship/marital status?
- When exactly was your last menstrual period?
- Have you ever been pregnant?
- Have you ever had an STI?
- How many sexual partners do you have?
- Do you have new sex partner (s)?
- Do you practice safe sex? Which methods?
- What event preceded you sore throat?
- Do you practice oral sex?
- What makes your sore throat better or worse?
- What have you taken for your sore throat?
- Describe the sexual activity preceding your vaginal bleeding.
- Have you inserted anything else into the vagina or used any new products (douches, cleansers, sex toys)?
- Do you have any pain associated or discomfort with the bleeding?
- If so, how severe is your vaginal pain on a scale of 0-10?
- How many pads/tampons do you use per day for post sex vaginal bleeding ?
- Are you experiencing vaginal discharge?
- Do you have vaginal itching or odors?
- Do you experience pain with urination? Frequency?
- When was your last pap smear? Was it normal?
- When did you have your clitoris pierced?
- Are you ready to quit smoking?
- Would you like information on smoking cessation?
- Do your family or friends tell you that you drink too much? Bleeding After Intercourse Essay Discussion Paper
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Gynecological Health Promotion
The patient will be educated on the risks to having unprotected sex, such as STI’s and pregnancy. For example, if she engages in oral sex, she will be taught about dental dam use. She will be offered options for contraception if it found that she is not currently on a birth control. Additionally, she will be informed of acceptable ways to keep the vagina healthy. SL will also be taught how to and when to perform the self-breast exams.
Knowing that the whole patient should be treated, this student would talk to the patient about her use of alcohol, nicotine and marijuana. The CAGE questionnaire would be given. Additionally, she would be provided with cessation options and pamphlets for support groups and other community resources.
References
Iqbal, U., Wills, C. Cervicitis. [Updated 2022 Sep 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562193/Links to an external site.
Lockwood, C. J. (2019). Key points for today’s ‘well-woman’ exam: A guide for ob/gynsLinks to an external site.Links to an external site.. Contemporary OB/GYN, 64(1), 23–29. https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=134229869&site=ehost-live&scope=site&authtype=shib&custid=s6527200Links to an external site.
Mohseni M., Sung, S,. Takov, V. Chlamydia. [Updated 2022 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537286/Links to an external site.
Schumann, J. A., Plasner, S. Trichomoniasis. [Updated 2022 Jun 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534826/Links to an external site. Bleeding After Intercourse Essay Discussion Paper
Olivia’s Post
Week 3 Focused SOAP Note
Case Study 2
Susan Lang is a 24-year-old Caucasian female presenting to the clinic complaining of bleeding after intercourse. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / ETOH only on weekends, 6-8 hard liquor/ daily, and marijuana smoking. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has some cramping during her menses for which she takes Midol. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies. Bleeding After Intercourse Essay Discussion Paper
temperature 97.8, pulse 68, BP 112/64, height 5’6” and weight
118 lbs. (which was the same as last year). BMI 19.04
· HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat
appears reddened.
· Lung: clear to auscultation
· CV: regular sinus rhythms without murmur or gallop
· Abd: soft, non-tender, liver normal,
· Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge,
no adenopathy, and bilateral nipple piercings.
· VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
· Cervix: friable, some petechia no cervical motion tenderness.
· Uterus: mid mobile, non-tender
· Adnexa: without masses or tenderness
· Perineum: wnl
· Rectum: wnl
· Extremities: full rom, skin clear, no edema, reflexes 1+.
· Neurological: CN II-12 grossly intact Bleeding After Intercourse Essay Discussion Paper
Patient Information:
SL, 24, Female, Caucasian
CC (chief complaint): bleeding after intercourse
HPI: A 24-year-old, female, Caucasian presents with bleeding after intercourse. She is bleeding from her vagina after intercourse. This issue started 6 weeks ago. Associated signs and symptoms include a sore throat for the last 3 weeks and a fever for a day or two. Sex exacerbated the bleeding and Tylenol helped relieve the fever. The patient did not specify the severity of this issue. However, she did state that she thought her sore throat and fever were related to allergies. She also has a history of tobacco, alcohol, and marijuana use. No other issues were noted.
Location: vagina
Onset: 6 weeks ago
Character: bleeding
Associated signs and symptoms: sore throat for last 3 weeks, fever for a day or two
Timing: after intercourse
Exacerbating/relieving factors: exacerbating: sex. Relieving: Tylenol for the fever.
Severity: patient did not state the severity
Current Medications: Midol PRN for cramping, Tylenol PRN for pain and fever
Allergies: no known medication or food allergies. Possible environmental allergies.
PMHx: no significant past medical history Bleeding After Intercourse Essay Discussion Paper
Soc & Substance Hx:
Tobacco: ½ pack per day (PPD) since age 14
Alcohol: ETOH only on weekends, 6-8 hard liquor/daily
Drugs: marijuana, frequency unknown
Exercise: jogs 3-4 times a week
Seatbelt use: always
Sunscreen use: occasionally
Fam Hx: no significant family history
Reproductive Hx:
Menarche: 13 years of age
Cycle duration: 28-32 days
Menses duration: 4-6 days
Pain: some cramping during menses
Tampon use per day: 3
ROS:
GENERAL: positive fever
HEENT: Throat: positive sore throat Bleeding After Intercourse Essay Discussion Paper
SKIN: not assessed
CARDIOVASCULAR: not assessed
RESPIRATORY: not assessed
GASTROINTESTINAL: not assessed
GENITOURINARY: Menarche: 13 years of age. Cycle duration: 28-32 days. Menses duration: 4-6 days. Pain: some cramping during menses. Tampon use per day: 3
NEUROLOGICAL: not assessed
MUSCULOSKELETAL: not assessed
HEMATOLOGIC: positive vaginal bleeding postcoital
LYMPHATICS: not assessed
PSYCHIATRIC: not assessed
ENDOCRINOLOGIC: not assessed
REPRODUCTIVE: positive sexually active. Menarche: 13 years of age. Cycle duration: 28-32 days. Menses duration: 4-6 days. Pain: some cramping during menses. Tampon use per day: 3.
ALLERGIES: No history of asthma, hives, or eczema.
Physical exam:
temperature 97.8
pulse 68
BP 112/64
height 5’6”
weight118 lbs
BMI 19.04
HEENT: positive anterior cervical adenopathy bilaterally, and throat
appears reddened.
Lung: clear to auscultation
CV: regular sinus rhythms without murmur or gallop
Abd: soft, non-tender, liver normal,
Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge,
no adenopathy, and bilateral nipple piercings.
VVBSU: positive slight frothy yellow discharge by cervix, clitoral piercing noted
Cervix: friable, some petechia no cervical motion tenderness.
Uterus: mid mobile, non-tender
Adnexa: without masses or tenderness
Perineum: no trauma or redness
Rectum: no pain, blood, hemorrhoids, nodules, or tears present
Extremities: full rom, skin clear, no edema, reflexes 1+.
Neurological: CN II-12 grossly intact Bleeding After Intercourse Essay Discussion Paper
Diagnostic results:
Throat rapid antigen test to test for strep
Throat culture to test for strep
Vaginal swab to test for sexually transmitted infections
Urine sample to check for sexually transmitted infections
Vaginal wet prep test to look at the fluid collected from the vagina under a microscope
Pap smear to check the cervix
A.
Trichomoniasis A59.9 (ICD Code Lists | CMS, n.d.)
This is a sexually transmitted infection caused by sexual contact. According to Magill’s Medical Guide symptoms include “frothy yellow or green vaginal discharge,…red patches on the cervix and vaginal walls” (Baker-Blocker, 2022). The patient has a yellow discharge and petechiae on the cervix. These two symptoms are usually a strong indicator that someone has trichomoniasis. Bleeding After Intercourse Essay Discussion Paper
Differential Diagnoses:
Differential 1: Cervicitis N72 (ICD Code Lists | CMS, n.d.)
According to the Salem Press Encyclopedia of health, “the most common cause of the condition is a sexually transmitted infection” (Harmon, 2022). Some symptoms of this include bleeding after intercourse, fever, and a friable cervix. My patient has a sexually transmitted infection, trichomoniasis. She also is bleeding after intercourse and friable cervix. She also had a fever was a few days. I think that this health issue is related to the trichomoniasis diagnosis and is a suitable diagnosis for this patient for the reasons listed above.
Differential 2: Streptococcal pharyngitis J02.0 (ICD Code Lists | CMS, n.d.)
My patient could have also been experiencing Streptococcal pharyngitis. You can have a sore throat, redness in the throat, fever, and anterior cervical adenopathy bilaterally with this health issue and those are all symptoms that the patient was having (Rizzo, 2022). Therefore, this is a good diagnosis for the patient.
Referrals: not at this time
Therapeutic interventions:
-metronidazole “dose: 500mg PO Q12 x7 days” (Epocrates, 2022).
-avoid sex until your treatment is completed, and all symptoms are gone
-all sex partners should get treatment to reduce reinfection Bleeding After Intercourse Essay Discussion Paper
(Baker-Blocker, 2022)
Education:
-take medication as directed and finish completely
-do not drink alcohol while on medication
-if nausea, vomiting, dizziness, or headache persist follow back up with the primary care provider because you could be having a reaction to the medication
-always use protection, such as a condom when having sex
-get tested for sexually transmitted infections when having sex without protection and with new partners
(Baker-Blocker, 2022)
Disposition of the patient: the patient may return to their home
Follow-up visit: if symptoms do not improve or persistent after one week you will need to follow back up
Health promotion:
-eat a well-balanced diet with protein, vegetables, fruits, carbohydrates, and good fats
-stay hydrated by drinking an adequate amount of water daily
-avoid drinking large amounts of alcohol
(Women, Caregiving, and COVID-19 | CDC Women’s Health, 2020) Bleeding After Intercourse Essay Discussion Paper
Reflection:
I learned that yellow frothy discharge and petechiae on the cervix are indicative of trichomoniasis. I also learned that sexually transmitted infections usually cause cervicitis. When I heard that this patient was having these specific symptoms, I knew that trichomoniasis was going to be the primary diagnosis. I learned that you could give a mega dose of metronidazole or a seven-day dose. I opted for the seven-day dose to ensure that my patient does not have a reaction to the medication. I felt like this was a very scholarly case study. I will use the information that I learned through this experience in my practice.
Additional questions related to the HPI/CC
- Would you describe your bleeding after sex as a small, medium, or large amount?
- Have you had any sexually transmitted infections in the past?
- Would you describe the nature of your intercourse as aggressive?
- Do you use protection, such as a condom when you are having sex?
- How many partners have you had sex within the last 2 months?
Reply to Jamelia L’s Post
Hello Jamelia, indeed your SOAP note is well presented with all major components present. First, the patient’s pertinent information is present, including her initials, age, gender, and ethnicity. You have also done a good job in the chief complaint, “Bleeding after intercourse.” This phrase indicates a health issue presented by the client during clinical assessment. History of present illness is also present with vaginal bleeding after sex reported as the major clinical issue and associated symptoms, including fever and sore throat for X3weeks. This essential information guides the healthcare provider in making differential and primary diagnoses. However, I disagree with Trichomoniasis as your primary diagnosis for this client. According to Abdul-Aziz et al. (2019), Trichomonas is characterized by a yellow or green foul-smelling vaginal discharge, burning, itching, redness or soreness in the genitals; and discomfort when peeing. On the contrary, the client’s chief complaint is bleeding after intercourse, implying she qualifies for a different primary diagnosis. Curry et al. (2019) report that PID is characterized by vaginal bleeding after sex, lower abdomen pain, an unusual vaginal discharge with a bad odor, a burning sensation with urination, and bleeding between periods. Therefore, Pelvic Inflammatory Disease (PID) qualifies as the primary diagnosis for this client. Bleeding After Intercourse Essay Discussion Paper
References
Abdul-Aziz, M., Mahdy, M. A., Abdul-Ghani, R., Alhilali, N. A., Al-Mujahed, L. K., Alabsi, S. A., … & Almikhlafy, A. A. (2019). Bacterial vaginosis, vulvovaginal candidiasis, and trichomonal vaginitis among reproductive-aged women seeking primary healthcare in Sana’a city, Yemen. BMC infectious diseases, 19, 1-10.
Curry, A., Williams, T., & Penny, M. L. (2019). Pelvic inflammatory disease: diagnosis, management, and prevention. American family physician, 100(6), 357-364.
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Reply to Olivia’s Post
Hello Olivia, your case presentation has included all major components of a SOAP note. For instance, the chief complaint, “Bleeding after intercourse,” indicates the reason for visiting the clinic. Additionally, the accompanying signs and symptoms, including fever and sore throat have been documented. Sexual intercourse has also been documented as the exacerbating factor, while Tylenol relieves the fever. Furthermore, the client’s current medications are included with no history of food or drug allergies. The client’s social and substance use history is also documented, indicating the use of tobacco and marijuana. Reproductive history is also well documented, indicating the client’s menarche, menses duration, cycle duration, and cramping during menses. Reproductive history is important when diagnosing and treating reproductive health issues. Your discussion has also included diagnostic tests, which is an essential aspect of the diagnosis and treatment process. However, the diagnostic result was not included, making the test irrelevant in making a differential diagnosis. Your primary diagnosis for this client is Trichomoniasis, which is characterized by frothy yellow or green vaginal discharge and red patches on the cervix and vaginal walls (Baker-Blocker, 2022). The client has these symptoms, qualifying for this primary diagnosis. Bleeding After Intercourse Essay Discussion Paper However, Pelvic Inflammatory Disease (PID) should be included as a differential diagnosis. Curry et al. (2019) report that PID is characterized by vaginal bleeding after sex, lower abdomen pain, an unusual vaginal discharge with a bad odor, a burning sensation with urination, and bleeding between periods. Therefore, the client qualifies for this diagnosis since she reports vaginal bleeding after sex. Nonetheless, PID is ruled out in this client since other pertinent symptoms, including lower abdomen pain and a burning sensation with urination, were absent.
References
Baker-Blocker, A. M. (2022). Trichomoniasis. Magill’s Medical Guide (Online Edition).
Epocrates. (2022). Point of Care Medical Applications | Epocrates. Epocrates.com. https://www.epocrates.com/Links to an external site.
Curry, A., Williams, T., & Penny, M. L. (2019). Pelvic inflammatory disease: diagnosis, management, and prevention. American family physician, 100(6), 357-364. Bleeding After Intercourse Essay Discussion Paper