Pelvic Note
Patient: Case 2
DOB: 3/8/86
Date:7/10/13
S.
CC: “Can’t stop itching X 3 weeks”
HPI: This G1P1 27 year old female presents with an itchy sensation, and describes dyspareunia.
She has never had anything like this before. She has not tried anything for this itch yet. She is especially
concerned because she and her boyfriend of several years just broke up after she found out he was
cheating on her. She’s especially worried that she could have HIV. She has noticed some increase in
white vaginal discharge. Denies any fevers or chills, fatigue, weight changes, recurrent infections,
nausea, vomiting, change in bowels, abdominal pain, change in urine, or change in stool.
PMH: Denies history of HIV, STI, HPV, yeast infections, DM, HTN, CVD, cancers, fibroids,
hypothyroidism, PCOS, CVA, anemia
Surgery: none
Meds: orthotricyclen low
Allergies: NKDA
Social Hx: unmarried, works as office manager. + ½ ppd; - EtOH, or drugs. One 8-year-old son
A&W.
Family Hx: Paternal grandfather died of MI at 69. Mother Denies family history of HIV, DM,
HTN, cancers, endocrine disorders, genetic diseases
O.
Vitals: T=98.6*F, R: 14, P: 72, BP: 116/72, Ht: 5’5”, Wt: 131 lbs.
General: No acute distress. Well-developed and well nourished.
Skin: Warm and dry no errythimitis. Capillary refill <3 seconds.
Throat: Good oral hygiene and no thrush or lesions.
Neck: No lymphadenopathy or thyromegaly. No deviation of trachea or bruits on auscultation.
Cardiac: No lifts, heaves, thrills, or murmurs
Respiratory: Clear breath sounds with no wheezing , rhales, ronchi, or stridor. No accessory
muscle use.
Abdomen: Non-tender no masses or bruits. Bowel sounds auscultated in all four quadrants.
Breast: No puckering, errythimitis, or nipple inversion. No masses or lymphadenopathy noted
on palpation.
GU/Pelvic: No errythimitis, lesions, warts, or discharge on vulva. No lymphadenopathy of
inguinal area. Inspection of cervix revealed white discharge. Bimanual exam showed no masses or
tenderness of uterus or ovaries.
A.
Dx: Vaginal itching x 3 weeks from Candida Albicans
Tx: Diflucan 150mg Pox1
DDX: HIV, HPV, STI, trichamonas vaginitis, pinworm vaginitis, vulva contact dermatitis
Tests: Rapid HIV negative, HCG negative, 10% KOH smear positive for buds and hyphae, Ph test
3
P.
Pending tests:
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

Patient given lab slip for the following blood work: TSH, CBC
Cultures collected for GC/Chlamydia and sent to lab
Pap smear collected and sent to lab
Treatment plan:

Diflucan 150mg Pox1
Education:





Patient informed that she was negative for pregnancy and HIV and had a positive test for yeast
Advised about smoking cessation and the health effects it can have especially when combined
with OCPs
Vaginal hygiene with avoiding baths, scented soaps and lotions, avoid douching, properly drying
vaginal area and not keeping wet clothes on, and wearing cotton underwear
Using condoms for back-up birth control for at least one month while taking antibiotics with
OCPs. Condoms also suggested as a general safe sex practice at all times.
Limit sweets, dairy products, and yeast foods
Follow up:


Will follow-up with patient with results of pending studies and schedule appointment if needed.
Emergency follow-up to ED if abnormal bleeding or severe pain.
Kristen Gumpf PA-S
Ali Zambanini PA-S
Case 3:
Assessment: Vulvar pain left side X 3 days
Dx: cervical cancer
Differential:
HPV
Chlamydia
Gonorrhea
Plan:
1. Pending Labs:
a. Pap smear conducted and sent out to lab- instructed to test for HPV if + for abnormal
cells
b. Cone biopsy done and sent to lab-via colposcopy
c. GC and Chlamydia cultures
d. BHcg, Re: r/o pregnancy
2. Treatment Plan:
a. Continue Ibuprofen use for pain
i. Pt instructed not to exceed 2400 mg/day
ii. ADR’s: GI bleed, nephrotoxicity, dyspepsia
Provider’s Notes:
Refer to gynecology oncologist if biopsy is positive.
Case 4:
Assessment: Vulvar rash x 6 months
Dx: genital psoriasis
Differential:
Paget’s disease
Candida vulvitis
Contact dermatitis
Eczema
Plan:
1. Pending Labs:
a. Pap smear conducted and sent out to lab
b. Biopsy of the outer vulva
c. Cone biopsy of the cervical lesion- with colposcopy
d. BHcg, Re: r/o pregnancy
2. Treatment Plan:
a. .1% hydrocortisone cream
Provider’s Notes:
Refer to gynecology oncologist if biopsy is positive.
Case 5:
Assessment: increased vaginal discharge, nausea
Dx: Chlamydia
Differential:
HPV
pregnancy
Gonorrhea
Plan:
1. Pending Labs:
a. Pap smear conducted and sent out to lab- instructed to test for HPV if + for abnormal
cells
b. Cone biopsy done and sent to lab- via colposcopy
c. GC and Chlamydia cultures
d. BHcg, Re: r/o pregnancy
2. Treatment Plan:
a. Levaquin 500mg PO q24h x 7 days
Provider’s Notes:
Refer to gynecology oncologist if biopsy is positive.