Week 7 – GYN and STI
In Canvas - Instructions – You are a NP in a PRIMARY CARE PRACTICE. Please succinctly note
in the following five (5) cases your responses. You are only asked to address actions or items
for this I
...
Week 7 – GYN and STI
In Canvas - Instructions – You are a NP in a PRIMARY CARE PRACTICE. Please succinctly note
in the following five (5) cases your responses. You are only asked to address actions or items
for this INITIAL PRIMARY CARE VISIT.
Case 1
You are a NP in a primary care clinic. You are seeing a pt with a CC of “bleeding in between
period.” She is a 48 G3P3 year-old woman who presents with intermenstrual bleeding x2 mos.
She is c/o BRB, but lighter than her normal period. She reports it can last 1-6 days. She denies
pain, hot flushes, or night sweats. She is monogamous, and is sexually active with her long-term
male partner. She denies any vaginal dryness and with no associated pain.
Q1: How would you further investigate and manage this pt?
I would address the following things:
Thorough history and physical using the PALM (polyps, adenomyosis, leiomyomata, malignancy)
and COEIN (coagulation disorders, ovulatory dysfunction, endometrial, iatrogenic, not yet
classified) screening tools, past medical history, last PAP smear, and current medications taken.
Physical exam to include a pelvic exam, breast exam, thyroid exam, pulmonary and
cardiovascular.
Q2: What are your ddx? Please select the three (3) MOST PROBABLE ddx, and your rationale
for selecting it as your dx or your r/o.
The differential ddx:
1) Uterine/endometrial Cancer bleeding pattern regular but heavy and prolonged,
enlarged uterus on examination, discrete masses may be palpated. The patient states
that she is having intermenstrual bleeding
2) Irregular bleeding due to OCP (oral contraceptive pills) irregular or heavy bleeding
related to OCPs or IUDs. The H&P would rule out the use of either modalities. The
patient is not on OCPs or IUDs
3) Endometrial polyps (leiomyomas) regular menses with intermenstrual bleeding.
Endometrial polyps are more likely to be malignant in postmenopausal women who
present with bleeding. The polyps should be removed to assess for malignancy and to
stop the bleeding.
Final DX: Endometrial polyps because they are a common cause of abnormal uterine
bleeding in both pre and post-menopausal women.
Case 2
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You have a new pt that is establishing care. She is 21 y/o nulliparous and not sexually active.
She asked you whether there is a need for her to have a “woman’s exam.”
Q1: How will you respond to her statement? Your response will be:
I would provide a print out of the latest guidelines and educate the patient about the current
recommendations. The current USPSTF guidelines recommend cervical cancer screening for
women 21 to 65 years of age with cytology PAP smear every 3 years. Women 30-65 need a PAP
smear and HPV testing every 5 years.
On visit #2, this same pt, RTC for review of her lab and pap result. Her pap result is as follows:
Aypical squamous cells of undetermined significance (ASCUS) - Low-grade squamous
intraepithelial lesion (LSIL), hrHPV negative
Q2: What is your interpretation of this result, and what will you tell your pt (next step)?
Atypical squamous cells of undetermined significance (ASCUS) are thin and flat they grow on
the surface of a healthy cervix. On the Pap smear, ASCUS are slightly abnormal squamous cells,
but the changes do not clearly suggest precancerous cells are present. ASCUS indicates some
abnormality, but the cause is not clear. If the cytology is unsatisfactory then repeat testing in 1
year (>30 yrs old) or continue routine screening (21-29 yrs old) then resume routine screening if
testing is normal at 3 years. If the cytology is positive for intraepithelial lesion or malignancy (+
or – HPV) referral for colposcopy required.
Low-grade squamous intraepithelial lesion (LSIL) indicates mild dysplasia or cervical
intraepithelial neoplasia (CIN) I negative for HPV high risk.
Next step: Pt is 21 years old she would need to repeat PAP with HPV testing in 12 months. If
results are unsatisfactory then refer for colposcopy if results are normal test at 3 years then
routine screening.
Case 3
28 y/o woman RTC for abnormal Pap smear result. She is very anxious as she thinks that she
might have cervical cancer. The Pap smear result is reported as “LSIL, hrHPV positive or
unknown.” She had a previous normal result at age 25 yrs. She has not had any postcoital or
intermenstrual bleeding or dysparenuia.
Q1: Any other information you would like to know?
-Do you have any chronic conditions?
-Have you ever had a STI?
-What medications are you taking?
-Do you use birth control, if so which kind of birth control?
-How many sexual partners do you have?
-What age did you start having sexual intercourse?
-Do you smoke or use any recreational drugs?
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Q2: Will your additional information change your management?
No, the guidelines will remain the same regardless of the HPI.
Q3: How should this pt be managed (next step)?
The pt has LSIL, (+) hrHPV or unknown normal result previously she needs to get a
Colposcopy
Case 4
A 36 year-old anxious woman self presented to clinic due to her vaginal d/c for the last 10 days.
c/o annoying d/c that saturates through her dayliner. “It smells, and it’s embarrassing.” Reports
white d/c with some itching and occasional burning on urination. She denies dyspareunia.
Reports had STI in her teens but cannot recall exactly what it was, but she was treated. Reports
2 male partners the past 6 mos. Reports 100% condom use.
Q1: You obtained all the additional information that you needed, what will do for your PE?
Focused exam to include general, pulmonary, CV, GI and pelvic exam
Whiff test, Wet mount, pH test, Pregnancy test, Urinalysis, STI tests (gonorrhea, chlamydia),
syphilis tests (rapid plasma regain or venereal disease research laboratory)
Labs Hepatitis panel
Case 5
A 46 year-old woman c/o heavy vaginal bleeding. H
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