NRNP 6552 Common Gynecologic Conditions, Part 1

Sample Answer for NRNP 6552 Common Gynecologic Conditions, Part 1 Included After Question

NRNP 6552 Common Gynecologic Conditions, Part 1

NRNP 6552 Common Gynecologic Conditions, Part 1

Week 4: Case Study 1- Episodic/Focused SOAP Note

Patient Information:

Initials: T.S              Age: 58                   Sex: Female           Race: African American


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CC (chief complaint): “brown discharge to pink spotting”

HPI: T.S., a 58-year-old African American woman, comes into the clinic complaining of brown discharge to pink spotting for many days last week. The patient’s medical record indicates a noteworthy medical history of type 2 diabetes, which has been partially managed through the use of glipizide and metformin, as evidenced by a recent A1C reading of 7.5. She has a nulliparous obstetric history, indicating that she has never experienced a pregnancy. The patient is current with regards to mammograms and underwent a colonoscopy one year prior, with results indicating no abnormalities. The patient’s pap smear history is within normal limits, with her most recent pap smear conducted two years ago indicating a negative for intraepithelial lesion or malignancy (NILM) result. The results indicate a lack of HPV presence, the presence of atrophic changes, and the absence of endocervical cells.

Location: vaginal

Onset: last week

Character: brown discharge to pink spotting

Associated signs and symptoms: none

Timing: none

Exacerbating/relieving factors: none

Severity: 6/10 pain scale

Current Medications: Glipizide 5 mg once a day and metformin 500 mg twice daily

Allergies:No known sensitivities to substances, foods, or environments.


Past Medical History: type 2 diabetes which is well managed with medication

Immunizations: Vaccination records are current.

Soc & Substance Hx: The patient is married but has never given birth and has no children. She shares a two-story, three-bedroom single-family home with her hubby. prohibits using tobacco, using e-cigarettes, vaping, or being around others who do. denies engaging in illicit or recreational drug use. denies having a drink. She says she is now a banker. She professes to be a devout Christian and puts a lot of importance on her spiritual health. She says she has a huge network of family, friends, and churchgoers. She eats three meals a day and says she tries her hardest. She naps for six to eight hours. She usually works out by taking the dog for a walk in the evening.

Fam Hx: Her father has diabetes and is 83 years old. Two years ago, her mother’s cervical cancer took her life.

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Surgical Hx:None

Mental Hx:denies sadness or anxiety. denies having ever used self-harm or had suicidal or homicidal thoughts.

Violence Hx:denies any safety worries or concerns

Reproductive Hx: GYN History: LMP eight years ago; most recent Pap test was two years ago; results were WNL; one partner; and no use of birth control; straight. OB History: Gravida: 0 Para: 0


GENERAL: The patient seemed healthy, and active, and denied having gained or lost weight.

HEENT: Eyes: denies any loss of vision, double vision, impaired vision, or yellow sclera. Denies hearing loss, sniffles, congested nose, runny nose, or hoarseness.

SKIN: denies having a rash or irritation.

CARDIOVASCULAR: denies feeling pressure, pain, or discomfort in the chest. No edema or palpitations.

RESPIRATORY: denies having a cough, sputum, or shortness of breath.

GASTROINTESTINAL: denies having anorexia, motion sickness, or diarrhea. neither blood nor stomach discomfort.

NEUROLOGICAL: denies experiencing headaches, vertigo, syncope, paralysis, ataxia, or tingling in the extremities. No modification to bladder or bowel control.

MUSCULOSKELETAL: denies experiencing stiffness, joint discomfort, back pain, or muscular pain.

HEMATOLOGIC: denies bruising, bleeding, or anemia.

LYMPHATICS: denies having larger nodes. denies having had a splenectomy.

PSYCHIATRIC: denies having a history of anxiety or depression.

ENDOCRINOLOGIC: reports a type 2 diabetes history. denies having a cold or heat sensitivity or sweating. No polydipsia or polyuria.

GENITOURINARY/REPRODUCTIVE: complaints of brown discharge to pink spots last week, lasting for many days. LMP eight years back, last Pap test two years ago, resulting in WNL, one partner, no birth control use, heterosexual. OB History: Gravida: 0 Para: 0

ALLERGIES: denies having ever had rhinitis, hives, asthma, or eczema.


Physical exam:

Vital signs: Temperature: 98.1°F, blood pressure: 140/88, pulse: 82, and respirations: 12. She is 272 pounds and 5’6″. (BMI 43.90).

Focused exam:

General: focused and awake. seemed to be well-groomed. The patient does not seem to be experiencing any immediate discomfort.

Abdomen: soft, overweight, and bowel sound-positive

VVBSU:  observed brown discharge,

Cervix: No cervical motion pain and brown blood were seen originating from the os

Uterus: being unable to evaluate owing to the physical habit

Adnexa: owing to bodily habit, impossible to evaluate

Diagnostic results: A1C last 7.5. Her Pap history is normal, and her most recent Pap revealed a NILM two years ago. Atrophic alterations, no endocervical cells, and HPV negative.


Primary and Differential Diagnoses

  1. Endometrial or Vaginal Atrophy: Brown spotting after menopause, as seen by the patient, is often an indication that blood has mixed with the discharge. According to studies, postmenopausal women often have vaginal atrophy, which may cause brown spotting and itching (Nappi et al., 2020).
  2. Endometrial polyps: Brown discharge seen before and after menstruation is another sign of polyps (Tanos, 2019). Painless polyps do not exist.
  3. UTI: Diabetic patients, like the one mentioned above, often get UTIs. In addition to the acute UTI symptoms, persistent UTIs may result in spotting, blood in the urine, or discharge (Wasserman & Rubin, 2023).

Primary diagnosis: Endometrial or Vaginal Atrophy

Additional Questions:

  1. What additional symptoms do you manifest besides the transition from pink discharge to brown spotting? This inquiry will facilitate the acquisition of additional data to bolster the primary diagnosis. Elia et al. (2019) have identified several symptoms that are associated with the condition, including vaginal dryness, itchiness, burning during urination, and recurrent urinary tract infections.
  2. What was the date of your most recent menstrual cycle? The inquiry in question is intended to ascertain whether the symptoms exhibited by the patient are attributable to menopause, as posited by Elia et al. (2019).
  3. Have you engaged in sexual activity recently? This inquiry will aid in ascertaining whether the individual’s symptoms are attributable to a sexually transmitted infection/disease.

The lining of the patient’s vagina becomes drier and thinner in vaginal atrophy. To corroborate this diagnosis, the inquiries will concentrate on symptoms like itchiness, burning, and discomfort during sex, among others (Nappi et al., 2020). Urinary tract issues such as urinary incontinence and UTIs are also a part of this illness.

Diagnostic tests: A Pap test,  ultrasound, urine sample, vaginal pH (acid test), and testing for vaginal infection will all be required to establish the main diagnosis and exclude the differentials (Nappi et al., 2019).

Treatment options: Only dehydroepiandrosterone (DHEA) and estrogen therapy are hormone treatments for vaginal atrophy (Pinkerton, 2021).

Health Promotion: Regular sexual activity improves vaginal tissue blood flow, which helps prevent vaginal atrophy (Nappi et al., 2019).

Patient Education: admonish the patient to stay away from vaginal irritants including douching, dye, shampoo, and cologne (Nappi et al., 2019).

Referrals: The patient needs to see a gynecologist for further assessment and treatment.

Follow-up: After two weeks, the patient must return to the clinic for an assessment of the effectiveness of the therapy.

Reflection: The material presented for the assigned case study is rather scant, supporting the main vaginal atrophy diagnosis. Brown spotting is a frequent symptom of menopause and may be brought on by several medical issues. However, DHEA is the most effective kind of therapy if the patient’s vaginal atrophy is proven (Pinkerton, 2021). To improve the patient’s general health and well-being, it is also important to encourage her to consume a good diet and exercise often. One of the key preventative methods for vaginal atrophy has also been suggested: regular sexual activity.


Elia, D., Gambacciani, M., Berreni, N., Bohbot, J. M., Druckmann, R., Geoffrion, H., Haab, F., Heiss, N., Rygaloff, N., & Russo, E. (2019). Genitourinary syndrome of menopause (GSM) and laser VEL: a review. Hormone Molecular Biology and Clinical Investigation0(0).

Links to an external site.

Nappi, R. E., Di Carlo, C., Cucinella, L., & Gambacciani, M. (2020). Viewing symptoms associated with Vulvovaginal Atrophy (VVA)/Genitourinary syndrome of menopause (GSM) through the estro-androgenic lens – Cluster analysis of a web-based Italian survey among women over 40. Maturitas140, 72–79.

Links to an external site.

Nappi, R. E., Martini, E., Cucinella, L., Martella, S., Tiranini, L., Inzoli, A., Brambilla, E., Bosoni, D., Cassani, C., & Gardella, B. (2019). Addressing Vulvovaginal Atrophy (VVA)/Genitourinary Syndrome of Menopause (GSM) for Healthy Aging in Women. Frontiers in Endocrinology10

Pinkerton, J. V. (2021). Selective Estrogen Receptor Modulators in Gynecology Practice. Clinical Obstetrics & Gynecology64(4), 803–812.

Links to an external site.

Tanos, V. (2019). Management of endometrial polyps. Women Health Care and Issues2(1), 01–07.

Links to an external site.

Wasserman, M. C., & Rubin, R. S. (2023). Urologic view in the management of genitourinary syndrome of menopause. Climacteric, 1–7.

I enjoyed reading your discussion post. I am intrigued by the information that you have presented, it captured my interest. I share your sentiments where you mentioned that a pap smear, ultrasound, urine sample, and testing for vaginal infection will be required to establish a diagnosis of endometrial or vaginal atrophy. In addition to the diagnostic investigations, I would also recommend endometrial biopsy and hysteroscopy. Postmenopausal women are at risk for endometrial malignancies and present with post-menopausal bleeding. 

The current recommendations from the American College of Obstetricians and Gynecologists postulated that sampling of endometrial tissue should be the first-line procedure in the management of abnormal uterine bleeding in women over 45 years old. Histopathological assessment of the endometrium is the gold standard for diagnosis of endometrial pathologies. Endometrial sampling can be performed as an outpatient or inpatient procedure (Husain et al., 2021).

Atrophic endometrium is one of the most common causes of abnormal uterine bleeding in women over 55 years old. This is due to hypoestrogenism which occurs in the menopausal period. Dilation and curettage are performed in order to obtain endometrial samples for pathological testing.  Patients with atrophy of the endometrium will have a diagnostic procedure like an endometrial biopsy performed to confirm this diagnosis. Research study has shown that approximately 90% of patients who are postmenopausal, asymptomatic, and have an endometrial thickness that is less than 7 mm was observed to have a trophic endometrium upon being biopsied (Husain et al., 2021).

In the past, an evaluation of intrauterine pathologies was performed with blind dilation and curettage of the uterus. This usually results in misleading diagnoses. Over the last decade, this procedure has been replaced by hysteroscopy. Currently, hysteroscopy is the gold standard procedure to diagnose and manage intrauterine pathologies in both premenopausal and postmenopausal women. Hysteroscopy is the only diagnostic procedure that facilitates direct visualization of the endometrial cavity. Owing to technological advancement, targeted endometrial biopsies are performed under direct visualization. Treatment of endometrial pathologies may also be performed without the need for dilation and curettage under anesthesia (Fagioli et al., 2020).

To complete a comprehensive assessment, all women require appropriate diagnostic investigations that are capable to diagnose gynecological health issues. Examples of appropriate diagnostic investigations are pelvic ultrasound, endometrial biopsies, and hysteroscopy.


Fagioli, R., Vitagliano, A., Carugno, J., Castellano, G., De Angelis, M. C., & Di Spiezio Sardo, A. (2020). Hysteroscopy in postmenopause: From diagnosis to the management of intrauterine pathologies. Climacteric23(4), 360–368.

Husain, S., Al Hammad, R. S., Alduhaysh, A. K., AlBatly, M. M., & Alrikabi, A. (2021). A pathological spectrum of endometrial biopsies in Saudi women with abnormal uterine bleeding. Saudi Medical Journal42(3), 270–279.

A Sample Answer For the Assignment: NRNP 6552 Common Gynecologic Conditions, Part 1

Title: NRNP 6552 Common Gynecologic Conditions, Part 1


Thank you for your response, I found it very insightful. I would like to provide some feedback on the diagnostic tests for the patient described in the case study. In your post you suggested several diagnostic tests, including a Pap test, ultrasound, urine sample, vaginal pH (acid test), and testing for vaginal infection. However, given the patient’s chief complaint of “brown discharge to pink spotting” and her medical history, I would approach the diagnostic workup slightly differently. Based on the patient’s symptoms and medical history, with vaginal atrophy as the primary diagnosis, I would prioritize such diagnostic tests as endometrial biopsy, transvaginal ultrasound, and vaginal pH and microscopy. Since postmenopausal bleeding can be associated with endometrial pathology, it would be prudent to perform an endometrial biopsy to rule out endometrial hyperplasia or malignancy. This test would help confirm or exclude other potential causes of the patient’s symptoms, such as endometrial polyps (Louie & Vegunta, 2022). By examining the tissue sample under a microscope, any atypical or malignant changes in the endometrial cells can be detected.

Transvaginal ultrasound can provide valuable information about the thickness of the endometrial lining and detect any structural abnormalities, such as polyps or masses. It can help to further evaluate the endometrium and assess the overall condition of the pelvic organs, including the ovaries. Transvaginal ultrasound is a non-invasive procedure that uses sound waves to generate images, allowing healthcare providers to visualize the pelvic structures. The clinical approach to dealing with postmenopausal bleeding requires a timely and efficient evaluation to rule out or diagnose endometrial carcinoma and endometrial intraepithelial neoplasia (Louie & Vegunta, 2022). Initially, transvaginal ultrasonography can be used as a sufficient method for evaluating postmenopausal bleeding. If the ultrasound images show a thin endometrial echo, the likelihood of endometrial cancer is very low. Therefore, transvaginal ultrasonography can be a reasonable first step in evaluating postmenopausal women who experience bleeding for the first time. If an endometrial sample taken blindly does not indicate endometrial hyperplasia or malignancy, further testing such as hysteroscopy with dilation and curettage should be considered for women with persistent or recurring bleeding.

In the case of incidentally discovering an endometrial measurement greater than 4 mm in a postmenopausal patient who is not experiencing any bleeding, it may not be necessary to routinely conduct an evaluation (Black, 2023). However, it is important to assess the situation individually based on the patient’s characteristics and risk factors. It’s worth noting that transvaginal ultrasonography is not an appropriate screening tool for endometrial cancer in postmenopausal women who do not have any bleeding symptoms.

While testing for vaginal infections is important, the pH measurement and microscopic examination of vaginal discharge can help differentiate between infectious causes and atrophic vaginitis. A high vaginal pH (>4.5) is commonly seen in infections like bacterial vaginosis, whereas a pH within the normal range but with the absence of significant inflammatory cells supports the diagnosis of atrophic vaginitis (Black, 2023). Microscopic examination can also identify the presence of clue cells which indicate bacterial vaginosis, or yeast cells which signify vaginal candidiasis. By focusing on these diagnostic tests, we can more specifically address the primary and differential diagnoses in a targeted manner. The endometrial biopsy would provide crucial information to rule out endometrial pathology, while the transvaginal ultrasound and vaginal pH and microscopy would aid in the evaluation of vaginal atrophy and potential infections. It is important to individualize the diagnostic workup based on the patient’s unique presentation and medical history. Consulting with a gynecologist or specialist would also be beneficial in determining the most appropriate diagnostic tests and confirming the diagnosis.


Black, D. (2023). Diagnosis and medical management of abnormal premenopausal and postmenopausal bleeding. Climacteric26(3), 222-228.

Links to an external site.

Louie, M. Y., & Vegunta, S. (2022). Abnormal uterine bleeding in perimenopausal women. Journal of Women’s Health31(8), 1084-1086.

Episodic/Focused SOAP Note Case Study

Patient Information:

SL, 24 y/o Caucasian Female


CC: Here for her well-woman exam and “regular care”

HPI: SL is a 24 y/o Caucasian female who presents today for her regular well-woman exam and pap smear. She has no concerns today except some postcoital bleeding that has been occurring for the past 6 weeks and having a sore throat for the past 3 weeks with fever for a “day or two”, she thinks it is her allergies. She rates her pain to her throat 3/10, she takes Tylenol 500mg to relieve the pain and had adequate relief, rating pain 1/10 after Tylenol. She describes the pain as “an annoying pain, more just sore than painful”.

Current Medications:

  1. Pamprin 2 caps PO every 6 hours PRN for pain, not to exceed 8 caplets in 24 hours. Last dose unknown.
  2. Tylenol 500mg 1-2 tabs PO every 4 hours PRN for pain/fever. Last dose was yesterday at 2100 for sore throat.

Allergies: NKDA, NKFA, no latex allergies, and no environmental allergies.


No medical history

The last tetanus is unknown; all childhood immunizations are up to date. She did not have the HPV vaccine. She declined the Influenza vaccine and COVID vaccines and boosters.

She has had no hospitalizations

Soc & Substance Hx:

SL exercises regularly by jogging 3-4 times per week, watching her diet, and eating a high-protein, high-calorie diet. She does drink soda daily, at least one 12oz can per day. She does not consume any other forms of caffeine and reports drinking at least 40oz of water daily. She reports smoking cigarettes daily 1/2ppd since the age of 14, has no interest in quitting, she reports drinking alcohol only on the weekends and consumes 6-8 hard liquor drinks/day, her CAGE assessment is negative at this time. She does report using marijuana starting at the age of 14 and smokes 2-3 times per week. She denies any vaping. She works full-time at a local business in town as an administrative assistant and really enjoys her job and the work she she’s and has health insurance coverage.  She does report wearing her seatbelt when she is in the car, “occasionally” uses sunscreen and does not text and drive. She lives alone in an apartment and reports being happy.

Fam Hx:


Surgical Hx:

No surgical history

Mental Hx:Denies any mental health history. Denies wanting to harm or hurt herself, has no suicidal or homicidal ideation currently, or has a history of having these thoughts.

Violence Hx:She denies being harmed or hurt by anyone currently or in her past relationships. She denies any sexual abuse or trauma in her childhood or past relationships.

Reproductive Hx: She still menstruates with regular cycles every 28-32 days, starting age 13. She reports her cycle lasts for 4-6 days and uses 3 tampons per day, she does have some cramping during her menses that is relieved with OTC Pamprin. Her last GYN exam was a year ago with a pap that was negative for HPV CG/CT. She is G0P0 and is currently sexually active with multiple sexual partners, she reports having 13 different partners in the last 12 months, all males except for one in the past year. She does report using condoms “sometimes” but does not like to use them because she feels like she gets irritation from them. She is unsure of what other birth control options are available.


GENERAL: No unexplained weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Denies any drainage from the eyes. Ears, Nose, Throat: Reports having some soreness to her pharynx, denies congestion, or runny nose. Denies hearing loss. Denies any pain in her ears bilaterally.

SKIN: No rash or itching. Denies any lumps to her breast bilaterally and no drainage from her nipples bilaterally.

CARDIOVASCULAR: Denies chest pain, chest pressure, or chest tightness. Denies any palpitations or edema.

RESPIRATORY: Denies any shortness of breath, cough, or sputum. Denies any wheezing.

GASTROINTESTINAL: Denies any nausea, vomiting, or diarrhea. She has no abdominal pain or blood in her stools and denies any changes in appetite.

NEUROLOGICAL: Denies any headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Denies any changes in bowel or bladder control.

MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, or stiffness. Denies any gait difficulties.

HEMATOLOGIC: Denies any anemia, bleeding, or bruising.

LYMPHATICS: Denies any enlarged nodes. No history of splenectomy was reported.

PSYCHIATRIC: Denies a history of depression or anxiety. Denies any suicidal or homicidal thoughts.

ENDOCRINOLOGIC: Denies any reports of sweating or cold or heat intolerance. Denies polyuria or polydipsia. Denies any unexplained weight loss or gain.

GENITOURINARY/Reproductive: Denies urgency, frequency, hematuria, or pain during urination. Denies any vaginal discharge or malodor. Denies any lumps or discharge to breasts and nipples bilaterally. Denies any pain during intercourse but does report some bleeding postcoital.

ALLERGIES: Denies having a history of asthma, hives, eczema, or rhinitis.


Physical exam: General appearance: Well nourished, no acute distress. She is alert and oriented and is cooperative with exams.

Vital signs: Temp. 97.8 oral, Pulse 68, Resp. 18, SPO2 98% Room Air, BP: 112/64.

Height: 167.6 cm

Weight: 53.6kg

BMI: 19.04

HEENT: Normocephalic, pupils equal and reactive, conjunctiva pink, without jaundice, sclera anicteric. Tympanic membranes are pearly gray to bilateral ears, and no fluid is noted. The pharynx has erythema noted, moist oral mucosa. Nares are clear bilaterally, with no tenderness to palpation over her sinuses.

Neck: Cervical neck tenderness upon palpation, and anterior adenopathy bilaterally noted.

Chest: lungs clear to auscultation, non-labored respirations, symmetrical expansion. No wheezing, crackles, or rales auscultated.

Cardiac: Heart rate regular, S1, S2 auscultated, no murmur, gallop, or edema.

Abdomen: soft, non-tender to palpation to her suprapubic region and bilateral lower quadrants. Bowel sounds active in all four quadrants. No organomegaly or masses were palpated.

GYN: No lesions, atrophy, or rectocele noted. The speculum is inserted, cervix has slight frothy yellow discharge noted, no cervical tenderness with the brush. The cervix is visualized, it is friable, some petechia noted, no cervical motion tenderness noted—cultures obtained at this time. The vaginal canal is without erythema and edema. No deformities were noted to the outer vaginal anatomy. The bimanual exam is negative for any nodules.

Breast: Medium-sized breast, pendulous, symmetrical nipples. No skin changes, nipple discharge, retraction, lesions, masses, or tenderness with palpation. There is no lymphadenopathy in the axillary region bilaterally. Fibrocystic changes bilaterally. Bilaterally nipple piercing in place.

External genitalia: Mons pubis diffuse patch of dark hair, no lesions.

Vulva/Labia Majora- no rashes, lesions, irritation. Clitoral piercing present

Bartholin glands- no masses, inflammation, or discharge.

Clitoris- No enlargement, and is non-tender.

Urethra- No prolapse or discharge and is non-tender.

Uterus- small, midline, firm, mobile, and non-tender with movement.

Adnexae- small, no masses, non-tender bilaterally.

Skin: warm and dry, no rashes noted. Skin turgor is less than three seconds.

Neurologic: awake, alert, and oriented x3. Gait is steady, PERRLA.

Psychiatric: Cooperative, appropriate mood and affect.

Diagnostic results:

  1. Pap smear screening: vaginal culture, HPV testing, thin prep pap test. Pap smears help detect cervical cancer, which is the third most common cancer in women worldwide (Bedell, Goldstein, Goldstein, & Goldstein, 2019). When a well-woman exam with a pap smear is completed, it can detect an infectious virus called Human Papillomavirus or HPV, which is the leading cause of cervical cancer-causing cervical carcinomas (Bedell, Goldstein, Goldstein, & Goldstein, 2019).
  2. STI testing: Chlamydia, Gonorrhea, Trichomonas: vaginal and throat cultures.

STIs are caused by different pathogens such as virus, bacteria, parasites and symptoms and lesions that are caused by these organisms can appear in various parts of the body (Bae & Lee, 2022). Untreated STIs can cause stillborn deaths, pelvic inflammatory disease, and sterility and being able to diagnose STIs is important for both treatable and non-curable diseases (Bae & Lee, 2022).

  • Rapid Strep POC

Pharyngitis is one of the leading reason for visits in doctors’ offices and emergency rooms each year with an estimated 11-18 million people seeking care for this each year (Mustafa & Ghaffari, 2020). Rapid antigen detection tests have been used for the last four decades to help diagnose strep throat, it’s a low cost, quick and effective way to diagnose (Mustafa & Ghaffari, 2020) in a clinical setting so that patients can receive treatment quickly.


1.  STI exposure Z20.2

High numbers of sexual partners accelerate the spread of sexually transmitted infections (STIs), such as chlamydia, gonorrhea, syphilis, HPV, and HIV (Copen, Leichliter, Spicknall, & Aral, 2019).  These infections can be spread through sexual contact and can be caused by bacteria, viruses, or parasites and are typically passed from person to person by blood, semen, or vaginal or other bodily fluids but can also be spread to infants during childbirth (Copen, Leichliter, Spicknall, & Aral, 2019). Patients can have symptoms such as painful or burning urination, discharge from the vagina or penis, malodorous vagina, vaginal bleeding, painful intercourse, pelvic pain, fever, and a rash over the trunk, hands, or feet (Copen, Leichliter, Spicknall, & Aral, 2019), or can be asymptomatic entirely. Treatment is dependent on the disease and what organism caused the infection. Antibiotics and antivirals are used the most to treat infections. This patient has signs and symptoms of an STI based on her history and exam. She has had multiple sexual partners in the last year, she has had postcoital bleeding, fevers, sore throat, cultures were positive for gonorrhea in the throat, vaginal cultures positive for chlamydia and trichomonas, bacterial vaginosis. Based on her exam and diagnostic results, she has an abnormal pap smear and positive STI exposure

Differential Diagnosis:

  1. Encounter for well woman exam with pap Z01.411

            Cervical cancer is the fourth most common cancer and is the fourth leading cause of cancer-related deaths amongst women in the world and almost all cervical cancers are caused by HPV which is easily detected and treatable by doing a yearly pap smear (Heena, Durrani, AlFayyad, Riaz, Tabasim, Parvez, & abu-Shaheen, 2019) in women over the age of 21. Educating young women on the importance and the reasoning behind well woman exams and papa smears is important in the screening and detection process. Well women exams can also detect breast cancers and STIs along with cervical cancers. This patient has drainage present along her cervix, is having postcoital bleeding, and has had multiple sexual partners in the past year, all of which are signs and risks for HPV and various STIs.

  • Pelvic Inflammatory Disease N73.9

Pelvic inflammatory disease (PID) is an infection of the upper genital tract that is typically caused by gonorrhea and chlamydia but can also be caused by bacterial vaginosis (BV) (Curry, Williams, & Penny, 2019). Women can be asymptomatic but most will show signs of PID by having abrupt onset of lower abdominal or pelvic pain that worsens with sexual intercourse, they may have abnormal uterine bleeding, polyuria, dysuria, or vaginal discharge (Curry, Williams, & Penny, 2019). Treatment should include antibiotic therapy and should be done quickly to help reduce the risks of infertility issues later in life. This patient has tested positive for chlamydia, gonorrhea, BV, and trichomonas and would be considered to have PID. She will need treatment for these infections with antibiotics Rocephin, Doxycycline, and Metronidazole (Curry, Williams, & Penny, 2019).

  • Strep throat J02.0

Many different viruses can cause sore throats, but to be considered strep throat the bacteria group A Streptococcus must be present (Sykes, Wu, Beyea, Simpson, & Beyea, 2020). Incubation period is typically 2-5 days after exposure by respiratory droplets or direct contact with the bacteria and typically show symptoms such as fever, pain with swallowing, red and swollen tonsils, white patches or streaks of pus on the tonsils, and swollen cervical lymph nodes (Sykes, Wu, Beyea, Simpson, & Beyea, 2020). This patient has reported having a sore throat for three weeks and exposure to the bacteria is unknown, she has had a fever, and cervical lymph swelling. She did test positive for gonorrhea after throat cultures were obtained. Based on the positive STI testing, I am able to rule out strep throat for this patient at this time.



  • Rocephin 500mg IM once
  • Doxycycline 100mg PO BID x14 days, #28, no refills
  • Metronidazole 500mg PO BID x14 days, #28, no refills

These medications are standard treatment that the CDC (2021) recommends for STIs that this patient has tested positive for.


  1. Urine pregnancy: negative CPT: 81025
  2. Pap smear screening: vaginal culture, HPV testing, thin prep pap test: results positive for chlamydia, trichomonas, positive Whiff test. CPT: 87624; 88175
  3. RPR CPT: 86592- Negative; Hepatitis C CPT: 86804- Negative; HIV CPT: 87389- Negative
  4. Wet mount CPT: Q0111- many WBC’s, many trichomonas, positive clue cells, positive amine.

These tests should be done any time someone has had having multiple sexual intercourse partners (Curry, Williams, & Penny, 2019) and are routinely obtained during a well woman exam with pap smear.


You are being prescribed three different kinds of antibiotics today, one you will receive here in the office prior to your leaving and is a one time injection, the other two you will pick up at the pharmacy. Be sure to take all of your antibiotics even when you begin to feel better. You will want to take them with food to help decrease the chance for an upset stomach and don’t be alarmed if you start to have diarrhea (Curry, Williams, & Penny, 2019), it is a side effect of the medications.

You have tested positive for chlamydia, gonorrhea, trichomonas, and bacterial vaginosis. You will need to abstain from sexual activity, including oral, until you have finished your antibiotics. You will also need to inform your partners that you have tested positive for an STI and they will need to be treated or they will cause reinfection or the spread of STIs to other partners. Safe sex practices are important to prevent the spread of diseases and help prevent pregnancy. I do want to tell you that STIs are a reportable disease to the state for tracking purposes.

There are multiple options for birth control to help prevent unwanted or unplanned pregnancies. Your options for birth control are limited because you are a smoker. The ones you can have and continue to smoke, which is not recommended, is an IUD called the ParaGard, can be inserted for up to ten years, and it is hormone free or Mirena, which can be inserted for up to seven years, which is progesterone only. You could also do an implant called Nexplanon that is inserted in your arm and stays in place for 3 years. There is also a progesterone only pill called the mini pill that you could take orally, it needs to be taken at the same time every day. There is a risk of reoccurring PID with an IUD since you have had STIs and PID previously (Curry, Williams, & Penny, 2019).

It is strongly recommended to stop smoking as it increases your chances of lung disease, cardiovascular disease, and diabetes. If you continue to drink and smoke marijuana, you have an increased risk of obtaining another STI and HIV (Curry, Williams, & Penny, 2019).

Disposition is to home she will need to return to the clinic in 3 weeks to have a urine test done to ensure the STIs have been cleared and no further antibiotics are needed and the possibility of starting a birth control option.

Reflection and further questions

            This patient needs education on STI prevention and risks, pregnancy prevention, smoking cessation and drug and alcohol abuse education. She will need to be followed closely to ensure her STIs are clearing and that her partners are all treated so that the spread of the STI doesn’t continue, and she is not reinfected.

During her GYN history, I would want to know if she has ever had any pregnancies, abortions, or miscarriages and if so when. I would also ask if she can remember the date of her last pap. I am also going to want to ask what her diet is like; her BMI is only 19 and she is a runner. Although her weight/BMI is unchanged from last year, this is something to monitor as a healthy BMI is 18.5. I also want to talk to her more about contraceptives and to see if she would be interested in being placed on one, either the mini pill or an IUD. I also need to know when her last menstrual cycle was, and we would need to test for pregnancy prior to starting on any birth control.

In her ROS I will need to ask her if she has a blood clotting disorder, if she does she would be at an increased risk for clots while being on birth control.

Her multiple partner history in a year is alarming to me as well as her admitting to “sleeping next to a stranger but does not remember how it happens” makes me want to ask questions regarding being hurt or violated sexually or the having the possibility of being sex trafficked.


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Centers for Disease Control and Prevention (2021). Sexually transmitted infections treatment guidelines, 2021. Sexually Transmitted Infections Treatment Guidelines, 2021 (

Copen, C.E., Leichliter, J.S., Spicknall, I.H., & Aral, S.O. (2019). Sexually transmitted infection risk reduction strategies among US adolescents and adults with multiple opposite-sex sex partners or perceived partner nonmonogamy, 2011-2017. Journal of The American Sexually Transmitted Disease Association, 46(11): 722-727. DOI: 10.1097/OLQ.0000000000001067

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