Description
Case Scenario 1:
Birth Control
How it works/ frequency of usage
% of effectiveness perfect use VS typical use
Combined contraception VS Progestin only method
Contraindicated for patients with/ who are
Pill
Combined pills will deliver progesterone and estrogen. Progesterone will suppress FSH and LH, suppressing the ovulation and thickens the cervical mucus, making it harder for sperm to impregnate. Estrogen suppresses FSH and stabilizes the endometrium to regulate the menstrual cycle
/Monophasic: 21 days are active pills and 7 days are placebo pills
Biphasic: 21-day cycle with fixed level of estrogen where the first 10 days of lower levels of progestin, second 4 days of higher levels of progestin and 14 days with no progestin
Triphasic: 21-day cycle with fixed level of estrogen and varied amount of progestin, 7 days are placebo pills for a full 28-day regimen
Fourphasic: First phase has high estrogen levels and no progestin, second and third phase have low estrogen and high progestin, fourth phase contains only estrogen and possible 2 placebo pills for 28 day regimen
Take 1 pill at the same time each day
(Alexander et al., 2023; Vallerand & Sanoski, 2023)
99.7% effective with perfect use and 91% effect with typical use (Woo & Robinson, 2019)
Combined contraception pills contain both progesterone and estrogen to prevent pregnancy through two different hormones that affect the endometrium and that affect ovulation; Both allow for independency to be taken at the same time each day (Alexander et al., 2023)
Contraindicated in women with history of blood clots, stroke, cardiovascular disease, history or current breast cancer, have liver disease, abnormal vaginal bleeding, tobacco use, have migraines with auras, diabetes mellitus with organ damage, uncontrolled hypertension, currently pregnant or breastfeeding (Alexander et al., 2023).
Patch
Combination of estrogen and progesterone to suppress FSH and LH, suppresses ovulation, and thickens the cervical mucus making it harder for sperm to penetrate /Replace once a week for 3 weeks and one week with no patch to allow menstruation for a total of 4-week period (Alexander et al., 2023).
99.7% effective with perfect use and 91% with typical use (Alexander et al., 2023).
Comes as a combination of estrogen and progesterone; allows for independency to be replaced at ease on their own time (Alexander et al., 2023).
Contraindicated in women with history of blood clots, stroke, cardiovascular disease, history or current breast cancer, have liver disease, abnormal vaginal bleeding, tobacco use, have migraines with auras, diabetes mellitus with organ damage, uncontrolled hypertension, BMI > 30, currently pregnant or breastfeeding (Alexander et al., 2023).
NuvaRing
Releases etonorgestrel and ethinyl estradiol to the vaginal epithelium thickening the cervical mucus/ Replace every 7 days for 21 days, then have one week without it inserted (Alexander et al., 2023)
99.7% effective with perfect use/ 93% effective with typical use (Kerns & Darney, 2023)
Only comes as a combination of estrogen and progesterone; allows for independent insertion and removal (Alexander et al., 2023).
Contraindicated in women who are pregnant or suspected to be pregnant, have liver diseases or hepatitis C, have breast or other progestin-sensitive cancer, have history of or current thromboembolic disease, have abnormal uterine bleeding or who smoke (Kerns & Darney, 2023)
Annovera
Releases segesterone acetate and ethinyl estradiol to the vaginal epithelium thickening the cervical mucus/ Replace every 21 days, then have one week without it inserted. Reusable for up to 13 cycles (Alexander et al., 2023)
99.7% effective with perfect use/ 93% effective with typical use (Alexander et al., 2023)
Only comes as a combination of estrogen and progesterone; allows for independent insertion and removal (Alexander et al., 2023).
Contraindicated in women who are pregnant or suspected to be pregnant, have liver diseases or hepatitis C, have breast or other progestin-sensitive cancer, have history of or current thromboembolic disease, have abnormal uterine bleeding or who smoke (Kerns & Darney, 2023)
DMPA (Depoprovera)
Delivers progestin to thicken the cervical mucus and thins the endometrium /Requires one injection every 12 weeks in clinic for IM and at home for subq (Woo & Robinson, 2019)
99.8% with perfect use and 94% with typical use (Woo & Robinson, 2019)
Depoprovera is a progestin-only contraceptive, so it is a better choice for postpartum, breastfeeding, or women who cannot tolerate estrogen; Can allow independency if subq route at home (Alexander et al., 2023).
Contraindicated in women with history of or current breast cancer, have liver disease, cardiovascular disease, abnormal vaginal bleeding (Alexander et al., 2023).
Implant
Inhibits ovulation by delivering progestin etonogestrel to the endometrium, thickening the cervical mucus. Additionally, the hormones make both the uterine and endometrial lining thinner. The thicker the mucus and thinner the lining, the harder it is for sperm to impregnate/ Replace every 3 years (Alexander et al., 2023).
99.95% with perfect or typical use (Woo & Robinson, 2019)
The implant is a progestin-only contraceptive; must be inserted by a healthcare provider but only requires replacement every 3 years
Contraindicated in women who are pregnant or suspected pregnancy, have liver diseases, have breast or other progestin sensitive cancer, have history of or current thromboembolic disease, have low bone density, or who have genital bleeding that has been abnormal. Additionally, women taking antiretrovirals, rifampicin, or few antiepileptics (Alexander et al., 2023).
Paragard (Copper IUD)
The copper in the IUD causes the endometrium to become inflamed, decreases the motility of sperm, and thicken the cervical mucus/ Replaced every 10 years (Alexander et al., 2023).
99.8% effective with perfect use and 99.2% effective with typical use (Woo & Robinson, 2019)
No hormone, just copper so it is not a combination or progestin only; it is a better choice for women who know they do not want to have children for the next 5-10 years, are breastfeeding, or do not want added hormones.
Contraindicated in women who have pelvic inflammatory disease, are currently pregnant or possible pregnancy, current or history of breast cancer, menorrhagia, copper allergy, or have Wilson’s disease (body has build-up of too much copper), have anatomical abnormalities such as fibroids or cervical stenosis (Madden, 2023).
LNG (levonorgestrel-releasing) IUD
Releases levonorgestrel to the endometrium, thickening the cervical mucus, thus making it harder for sperm to permeate/ Mirena: Replaced every 7 years (52 mg of LNG/avg 20 mcg daily release)
Liletta: Replace every 3-6 years (52 mg of LNG/avg 20 mcg daily release
Kyleena: Replaced every 5 years (19.5 mg of LNG/avg 9.8 mcg daily release)
Skyla: Replaced every 3 years (13.5 mg of LNG/avg 8 mcg daily release)
(Alexander et al., 2023; Woo & Robinson, 2019).
Mirena: 99.5% effective with perfect use and 99.3% effective with typical use
Liletta: 99.9% effective with both typical and perfect use
Kyleena: 99.8% effective with both typical and perfect use
Skyla: 99.7% effective with perfect use and 99.6% effective with typical use
(Kerns & Darney, 2023)
The IUD is a progestin-only contraceptive; must be inserted by a healthcare provider, but only requires replacement every 3-7 years (Alexander et al., 2023)
Contraindicated in women with pelvic inflammatory disease, are pregnant or may be pregnant, current or past history of breast cancer, have anatomical abnormalities to the uterine cavity including fibroids or cervical stenosis (Madden, 2023)
SOAP Note
Demographic Data
19-year-old/ Female
Subjective
CC: Irregular menses
HPI:19-year-old female presents to clinic for an annual physical examination. Patient complains of irregular menses, with one menses every 3-4 months. Patient complains of irregular menses for the past 2 years with one menses every 3-4 months. Patient reports being sexually active, not using any contraceptives, and only using condoms as protection “occasionally”. Patient denies past pap smears or pelvic exams.
What other relevant questions should you ask regarding the HPI?
What age was your first menarche?
When was your LMP? During menstruation, do you experience any abdominal pain, cramping, vaginal pain? Is your menses typically heavy? How many days does your menses usually last? Do you bleed or spot in between periods or after sexual intercourse?
What other medical history questions should you ask?
PMH/PSH: Denies any significant history. But would still ask specifically about any personal history of bleeding or clotting disorders, migraines with/without auras, liver disease, breast cancer, depression, or thyroid dysfunction? Do you have a history of or currently have any eating disorders such as bulimia or anorexia nervosa, binge-eating disorder?
Gravida/Para: G0P0
Family History: Do you have a family history of breast cancer, ovarian cancer, or other cancers? Do you have a family history of any heart disease, lung disease, diabetes, thyroid problems or any autoimmune diseases such as Hashimoto’s disease?
Allergies: Are you allergic to any food, medications, or have any environmental allergies?
Medications: Are you currently taking any prescribed, over the counter, or natural/herbal medications? Have you ever tried any birth control methods in the past? If so did you react well, any side effects, or anything that you liked/did not like about the method you tried?
Immunizations/Preventive Health Maintenance: Are you up to date on all your immunizations? Specifically, have you received your series of 3 HPV, meningococcal B or hepatitis B vaccinations?
What other social history questions should you ask?
Social History:
Home: What is your current living situation? Do you live with anyone? Do you feel safe at home?
Education/Employment: What is your highest level of education? Are you currently in school/working? If so, do you have any exposure to harmful chemicals at school or work?
Activities/Exercise: Do you exercise, how often, for how long, what type of exercise? (eating disorders and excessive exercise increase risk for oligomenorrhea)
Nutrition: Do you follow a specific diet? Eat/avoid certain foods?
Drugs/Alcohol: Do you smoke tobacco or use any vapes? Do you drink alcohol, if so which alcohol, how often, and how many drinks? Do you use any illicit drugs including IV drugs?
Sexuality: How long have you been sexually active for? How many partners have you been with or currently have? Are your partners male, female, or both? Have you and your partner(s) been tested for any STIs when you were together? Have you experienced or been a victim of intimate partner violence?
ROS:
General: Are you experiencing any fevers, chills, night sweats, weight loss/weight gain, fatigue?
HEENT: Are you experiencing any headaches? Any eye pain, blurred vision, or photophobia? Any ear pain, feeling of ear fullness or tinnitus?
Cardiovascular: Any chest pain or palpitations? Any swelling in lower extremities?
Respiratory: Are you short of breath or experiencing any dyspnea? Any new or worsening cough/wheezing?
Endocrine: Any sensitivity or intolerance to cold or hot temperatures? Any increased thirst, urination, or hunger?
Gastrointestinal: Any difficulty swallowing? Any nausea or vomiting? Any recent changes in bowel habits? Do you experience any constipation or diarrhea? Any black, bloody, or tarry stools?
Genitourinary: Do you experience any urinary urgency, frequency or incontinence? Are you experiencing any dysuria or burning with urination? Any irregular menses, spotting between periods or changes to your period? Are you experiencing any dyspareunia or post-coital bleeding? Any vaginal discharge or dryness? Any vaginal pruritus or odor?
Musculoskeletal: Any muscle weakness or fatigue?
Skin/Breasts: Any new or changing moles, lesions, rashes? Any changes in breast sensitivity?
Hematologic/lymphatic: Any increased or excessive bruising or bleeding? Any swelling or tenderness in your neck, axilla, groin?
Neurologic: Any numbness or tingling in face or extremities? Any tremors, spasms, or seizures?
Psychiatric/mental health: Any increased stress or anxiety? Any depression or suicidal ideation?
Objective
Vital Signs: WNL
Take patients’ weight, height and calculate BMI (Welt & Barbieri, 2022)
Physical Exam:
General: Visual patient appearance for any acute distress
HEENT: Palpate head for tenderness or bumps. Assess pupils for shape, size, reactivity, light accommodation. Assess eyes for any swelling, redness discharge. Assess TMs and ear canal for any swelling or discharge. Assess quality and color of mucous membranes. Visualize dentation to look for erosion. Assess uvula for deviation and tongue for swelling. Palpate neck for goiter.
Cardiovascular: Auscultate heart sounds for S1 and S2 heart sounds. Not any murmurs, rubs or gallops. Determine rate and rhythm. Palpate pulses in both upper and lower extremities, determining that they are +2 and symmetrical. Assess for lower extremity edema. Assess capillary refill.
Respiratory: Auscultate anterior and posterior lung fields for adventitious breath sounds. Assess accessory muscle use and anterior posterior chest expansion.
Gastrointestinal: Auscultate bowel sounds in all 4 quadrants to determine if normoactive. Palpate abdomen for any tenderness, masses, or hernias. Palpate liver and spleen for hepatomegaly or splenomegaly.
Lymph nodes: Palpate all lymph nodes in the neck, axilla, and groin for tenderness or swelling.
Musculoskeletal: Observe patient gait, assess muscle strength in all extremity and perform passive/active ROM.
Skin: Palpate skin for temperature and diaphoresis. Assess for any rashes, lesions or irregular moles. Assess for any acne on face or back. Assess for signs of hirsutism such as hair on upperlip, chin, or male pattern baldness. Assess for striae or hyperpigmentation on skin folds in neck, elbows, axilla, knees.
Breast: Palpate breast for breast tenderness, masses and adjacent lymphadenopathy in the area. Visualize breast for any peau d’ orange, retraction, erythema or rash, discharge.
Gynecologic: Assess external genitalia for vesicles, lesions, masses. Note any vaginal dryness or discharge.
Neurologic: Assess patients’ alertness and orientation. Assess for any numbness, tingling or tremors in face or extremities. Perform cranial nerve assessment on CN I-XII.
Psych/mental health: Observe patients’ mood and affect. Observe for any auditory or visual disturbances.
POC testing: Pregnancy (-)
What point of care testing (POCT) would you perform or order for this patient?
Other than the pregnancy test that was already performed, it is appropriate to perform a nucleic acid amplification test (NAAT). The NAAT would test for chlamydia and gonorrhea (Rietmeijer, 2024). The patient is at high risk for STI as she is a 19-year-old female who is sexually active and reports not using protection during each sexual encounter (Rietmeijer, 2024).
Patient states she has not had a pap smear, is it appropriate to perform a pap on this patient? Why or Why not?
A pap smear would not be performed for this patient as both the USPSTF and ACOG advise against it for females under age 21 (USPSTF, n.d.; ACOG, 2021). Even though the patient is sexually active, contraceptive services are able to be administered without a cervical cancer screening (Alexander et al., 2023). It is recommended by ACOG and USPSTF to begin pap-smears at age 21 or older with re-screening every 3 years (USPSTF, n.d.; ACOG, 2021).
Assessment/Diagnosis:
Working Diagnosis
Secondary oligomenorrhea (ICD-10: N91.4): secondary oligomenorrhea is diagnosed when females who have their menses by age 15 miss their menstrual period by 35 days or have less than 9 periods a year (Welt & Barbieri, 2022). The cause of secondary oligomenorrhea needs to be evaluated but can be due to multiple different etiologies including polycystic ovary syndrome (PCOS), hypothalamic dysfunction, hyperprolactinemia, hypothyroidism, and menopause (Welt & Barbieri, 2022). Initial evaluation begins with serum hCG to rule out pregnancy (Welt & Barbieri, 2022). Patient history and physical examination will only help r/o other causes; with history focusing on weight changes, eating habits, exercise habits, and current systemic illnesses (Welt & Barbieri, 2022). Physical exam will include assessing for hirsutism, acne, BMI, galactorrhea, and hyperpigmentation (Welt & Barbieri, 2022). Labs will include serum FSH, estradiol, progesterone, testosterone, DHEA, prolactin, and TSH (Welt & Barbieri, 2022). The history, physical, and labs will help determine cause of secondary oligomenorrhea, with treatment focusing on treating the cause; subsequently treating the oligomenorrhea. The patient is a 19-year-old female with symptoms of oligomenorrhea as she states her menstrual cycle is every 3-4 months for the past 2 years.
Differential Diagnosis
Polycystic ovary syndrome (PCOS) (ICD-10: E28.2): PCOS symptoms include menstrual dysfunction, hyperandrogenism, polycystic ovaries, metabolic issues, and mood disorders (Barbieri & Ehrmann, 2022). Patients with PCOS typically present with oligomenorrhea or amenorrhea (Barbieri & Ehrmann, 2022). Patients will also have male pattern hair growth, acne, deepening of voice, hirsutism (Barbieri & Ehrmann, 2022). A transvaginal ultrasound will reveal polycystic ovaries in these patients (Barbieri & Ehrmann, 2022). Patients with PCOS tend to have a BMI> 30, insulin resistance, and may have higher risk for DMII (Barbieri & Ehrmann, 2022; Welt & Barbieri, 2022). The patient is a 19-year-old female with symptoms of oligomenorrhea as she states her menstrual cycle is every 3-4 months for the past 2 years.
Functional hypothalamic dysfunction (ICD-10: E23.3): Hypothalamic dysfunction typically occurs due to metabolic activity caused from type 1 or type 2 diabetes mellitus, celiac disease, hemochromatosis, eating disorders or strenuous exercise (Welt & Barbieri, 2022). These systemic illnesses affect the secretion of gonadotropin-releasing hormone, causing a decrease in gonadotropins, follicular development, luteinizing hormone, and estradiol, effectively decreasing menses (Welt & Barbieri, 2022). Patients will present with oligomenorrhea, BMI < 18.5, and symptoms of their systemic illness (Welt & Barbieri, 2022). Females with eating disorders such as anorexia or bulimia will also present with dental carries, erosion, and parotid gland swelling (Welt & Barbieri, 2022). The patient is a 19-year-old female with symptoms of oligomenorrhea as she states her menstrual cycle is every 3-4 months for the past 2 years.
Hypothyroidism (ICD-10: E03.9): Thyroid disorders can be contributed to oligomenorrhea and amenorrhea due to the effects thyrotropin-releasing hormone has on releasing TSH and prolactin (Welt & Barbieri, 2022). Patients may present with irregular menses in addition to fatigue, weight gain or high BMI, cold intolerance, dry skin, hoarseness, depression, galactorrhea, and bradycardia (Surks, 2022). In patients with hypothyroidism, 16% complain of irregular menses, especially for those under age 40 (Surks, 2022). Diagnosis is made through thyroid panel testing, history and physical assessment. The patient is a 19-year-old female with symptoms of oligomenorrhea as she states her menstrual cycle is every 3-4 months for the past 2 years.
Plan:
Diagnostic plan (Welt & Barbieri, 2022)
Labs: CBC, CMP, A1C, TSH, T3 and free T4, FSH, LH, estradiol, progesterone, total testosterone, DHEA, prolactin, Lipid panel
Testing for HIV and Hepatitis C should be included as well as the patient meets criteria for testing. The USPSTF recommends testing all patients at least once in their lifetime and it is unknown whether she has been tested for either yet (Rietmeijer, 2024; USPSTF, n.d.). Testing for HIV begins with ELISA, if positive a western blot will be completed to confirm diagnosis. Testing for HCV is done through serum hepatitis C antibody testing (Alexander et al., 2023).
Imaging: transvaginal ultrasound
Prescription:
What will you prescribe for this patient? Why?
Plan of care will depend on if the patient wants to get pregnant and patient preference for regulating hormones. If pregnancy is not wanted at this time or planned for the near future, the patient can choose either combined oral contraceptives or levonorgestrel intrauterine device (IUD) (Welt & Barbieri, 2022)
Mirena (levonorgestrel) 52 mg IUD
Has to be inserted into uterine cavity within 7 days of menses. Should be removed/replaced every 5-7 years (Vallerand & Sanoski, 2023)
OR
Sprintec-28 (35 mg ethinyl estradial/0.25 mg norgestimate) PO Daily:
This is a combined oral contraceptive. This medication works as a monophasic contraceptive, delivering a fixed dose of combined estrogen and progestin for a 21-day cycle. Take at the same time daily. If you miss a dose, take the missed dose as soon as you remember. Can take with or without food. This is a contraceptive to prevent pregnancy continue to use condoms for protection against STIs. If you become pregnant, stop taking the medication and call the office (Vallerand & Sanoski, 2023)
Patient Education
In addition to the medication education as described above, educate the patient that IUD or the combined oral contraceptive are only protecting against pregnancy not any STIs. Educate the patient on safer sex practices such as using a condom with each sexual encounter not sometimes as condoms will reduce the risk of STIs. Routine testing for STI is important whether using protection or not. Testing should be completed annually or when symptoms arise (Vallerand & Sanoski, 2023; Rietmeijer, 2024)
Referral/Follow-up: Follow-up in clinic in 2 weeks for lab results.
Health Maintenance: Not due to pap smear for another 2 years
Case Scenario 2:
Complete the charts and answer the case scenario.
2018 USPSTF Guidelines
2021 ACS Guidelines
Age 21-24
The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years (USPSTF, 2024).
Age 25-29
The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years (USPSTF, 2024).
The ACS recommends that individuals with a cervix initiate cervical cancer screening at age 25 y and undergo primary HPV testing every 5 y through age 65 y (preferred). If primary HPV testing is not available, individuals aged 25-65 y should be screened with cotesting (HPV testing in combination with cytology) every 5 y or cytology alone every 3 y (acceptable) (strong recommendation) (Fontham et al., 2020).
Age 30-65
For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) (USPSTF, 2024).
The ACS recommends that individuals with a cervix initiate cervical cancer screening at age 25 y and undergo primary HPV testing every 5 y through age 65 y (preferred). If primary HPV testing is not available, individuals aged 25-65 y should be screened with cotesting (HPV testing in combination with cytology) every 5 y or cytology alone every 3 y (acceptable) (strong recommendation)Fontham et al, 2020).
Age 65 and older
The USPSTF recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer (USPSTF, 2024).
The ACS recommends that individuals with a cervix who are older than age 65 y, who have no history of cervical intraepithelial neoplasia grade 2 or a more severe diagnosis within the past 25 y, and who have documented adequate negative prior screening in the 10-y period before age 65 y discontinue cervical cancer screening with any modality (Fontham et al., 2020).
American Cancer Society Recommendations for the Early Detection of Cancer in Average-Risk, Asymptomatic Adults
CANCER SITE
POPULATION
TEST OR PROCEDURE
RECOMMENDATION
SUMMARY
Breast
Women of average risk ages 40 + and women of a younger age with family history of breast cancer
Monthly self exams and Mammogram
Women ages 40-44 may have a mammogram.
Women 45-54 should have an annual mammogram.
Women 55 and older may screen every other year. Screening should continue as long a s a women is in good health and expected to live 10 + years (American Cancer Society, 2024).
Cervix
Women ages 25 and older
Pap test every 3 years and HPV test every 5 years
Women aged 25 to 65 should have a Pap test every 3 years and be co-tested for HPV every 5 years. Women 65+ with two negative tests may discontinue screenings (American Cancer Society, 2024).
Colorectal
Women ages 45-75 with average risk factors.
FOBT stool or Colonoscopy as directed
Women ages 45 to 75 should be screened annually with a FOBT or Colonoscopy based on their Health Care Providers recommendations. Ages 75-85 may be screened depending on their risk factors and medical history. Screening alert 85 is not recommended (American Cancer Society, 2024).
Endometrial
All women at menopause should be told about the symptoms and to contact their doctor. Women at high risk with Lynch syndrome or the HNPCC gene should be screened at age 35 (American Cancer Society, 2024).
Endometrial biopsy.
Pelvic exam
At menopause all women should be informed about the signs and symptoms of endometrial cancer and report any discharge or unusual bleeding to their doctor. At this time there is no early screening (American Cancer Society, 2024).
Ellen is a 35-year-old female whose latest Pap smear result reports HSIL with positive HPV. Ellen reports no h/o of STIs or previous abnormal Pap smear results. She had only two previous Pap tests 7 and 14 years ago. Ellen is G1P0 with a TAB at age 25. She and her partner are undecided whether they want to have children. She has been monogamously married to a female partner for the last 5 years, but she considers herself bisexual and has previously engaged in sexual activities with males and females. Ellen denies any significant medical history or current health problems. Her LMP was 5 days ago and her VS are WNL. Her BMI is 24.7. Her pregnancy test is negative.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
Subjective:
What other relevant questions should you ask regarding the HPI?
Are you in any pain?
Do you feel safe in your relationship?
Are you feeling depressed or finding less interest in doing things?
Has your partner been tested for HPV?
Does anyone in your family have a history of any cancer including breast uterine, endometrial, ovarian, or cervical cancer?
Are you thinking about becoming pregnant in the next year?
Are you presently using condoms?
Do you experience any bleeding after sexual intercourse?
Have you noticed any lesions or a malodorous vaginal discharge?
Do you have any dysuria, or pruritus?
Do you have migraines?
How often do you have your menstrual period and how long does it last?
Would you describe your periods as heavy, regular or light?
Are you taking any medications or using any contraceptive measures? Are you interested in discussing your options for contraception today?
Are you current with your COVID-19,TDAP, Influenza, MMR, Varicella, and Hepatitis B immunizations?
Did you ever have the HPV vaccinations?
Do you smoke tobacco, drink alcohol, or use drugs?
What kind of work do you do?
Objective:
What other point of care testing (POCT) would you perform or order for this patient? Why?Refer to an OB/GYN for observation with colposcopy. with directed biopsy if indicated. The patient may need an excision LEEP procedure, cryotherapy or laser ablation based on findings and HSIL Grade (UpToDate, 2024). Repeat HPV testing in 6 and 12 months for up to two years Vaginal pH and or Wet Mount, VDRL, NAAT, RPR, PCR for trichomoniasis, HCV and HIV testing due the patient’s sexual history and presence of HPV.
Assessment/Diagnosis
R87.810 Cervical high risk human papillomavirus (HPV) DNA test positive &
R87.613 High grade squamous intraepithelial lesion on cytological smear of cervix.
HPV is a slow growing DNA virus of the Papovavirus family. There are 70 strains identified and HPV makes you at higher risk for cervical cancer and developing genital warts.
High-grade squamous intraepithelial lesions are premalignant but advanced cervical lesions in patients over 25 that require more aggressive treatments to prevent the progression to cancer (UpToDate, 2024).
Plan:
What will you prescribe for this patient? Refer to OB/GYN for colposcopy and biopsy and excision procedure based on findings. HSIL poses a greater risk for developing into cancer and this patient is undecided if she wants to become pregnant at 35 years of age (UpToDate, 2024).
What patient education is important to include for this patient? It is important to treat the HSIL promptly, to prevent it from becoming cancerous and impacting your potential fertility and health.
Is there any education or advice you would give to Ellen regarding her current female partner? HPV is often shared between sexual partners. You both should continue to have regular pap smears and HPV testing. Your partner may also want to receive the HPV vaccination to protect herself. HPV can infect areas that are not protected by condoms (Cash, 2024).
What pharmacological and nonpharmacological education and advice can you give Ellen to help with her HSIL condition? A colposcopy will determine if an excision procedure is necessary. HPV vaccination will not resolve an active HPV infection but it may help with prevent the recurrence of HPV in patients over the age of 27 (UpToDate, 2024).
Pharmacological: HPV vaccination will not resolve an active HPV infection but it may help with prevent the recurrence of HPV in patients over the age of 27. Iquimod 5% topical application to HSIL weekly for 12 weeks have higher rates of histologic regression than those who do not (UpToDate, 2024).
Non-Pharmocological: A colposcopy will determine if an excision procedure is necessary. Observation and repeat testing in 12 months is necessary to prevent HSIL from progressing to cancer. The risk of recurrence of HSIL and HPV is lower among patients who have the excision procedure and adjuvant HPV vaccination (UpToDate, 2024).
Subjective
CC: 35-year-old female tested positive for HPV and HSIL.
HPI: History of therapeutic abortion at age 25. Patient is Bisexual and in committed monogamous relationship with wife of 5 years.
Medications: No medications
Allergies: NKDA
LMP: 3/1/2024
Gyn/OB history: No history of STI’s. TAB at the 25.
PMH: No previous medical history.
Chronic Illness/ Major trauma: No chronic illness or major trauma reported by patient.
Family Hx: Family history is unremarkable for cancer, diabetes, heart disease, or mental health disorders.
Social Hx: The patient does not smoke, drink alcohol or use drugs. The patient is in a monogamous relationship with wife of 5 years.
ROS
General: Patient denies fever or chills. The patient reports denies unintentional weight gain or weight loss.
Eyes: Denies change in vision or loss of vision, eye pain, sensitivity, or discharge.
Ears, nose, mouth & throat: Denies ear pain, loss of or decreased hearing, ringing of the ears, and difficulty chewing or swallowing.
Cardiovascular: Denies chest discomfort or tightness. Denies abnormal heartbeat or palpitations. Denies shortness of breath.
Respiratory: Denies having an active cough, or shortness of breath.
Gastrointestinal: Patient denies nausea, vomiting, constipation, diarrhea, or abdominal discomfort/pain.
Skin: Denies rash, itching, abnormal skin, or recent injury.
Musculoskeletal: Patient reports pain 0/10.
Allergic: Denies history of seasonal allergies, allergic rhinitis,
Immunologic: Denies history of HIV, TB, or other recurrent infectious diseases.
Endocrine: Denies polyuria, polydipsia, and polyphagia. Denies history of blood sugar instability.
Genitourinary: Patient denies frequency, urgency, or incontinence. No signs or symptoms of infection.
Gynecological: The patient denies pain after
