POST 1 
Gayle is a 25-year-old woman who comes to your office for her first Pap smear exam. She tried to have a Pap smear before, but she was unable to tolerate insertion of the speculum. She cannot use tampons during her menses due to pain at her introitus when she tries to insert the tampon. Her last boyfriend broke up with her after 6 months because she was unable to have intercourse with him due to pain at her introitus when trying to insert his penis. The patient cannot remember exactly when this pain started because she didn’t attempt to use tampons until she was 19 years old. She did not attempt intercourse until she was 21 years old. She thinks she noticed this pain the first time she attempted to insert a tampon but cannot be sure. She is extremely anxious and almost in tears about the thought of having a Pap smear, but thinks she “must” have one even though she reports being unable to ever have vaginal intercourse.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
CC: “I am here today because I know I have to have a pap smear. I am scared and have pain every time I try to place something in to my vagina whether it be a tampon or trying to have sex. I don’t know what else to do”
HPI: Gayle is a 25 year old female who is here to attempt to have a pap smear. She has tried to have a pap smear with no success due to being unable to tolerate speculum insertion. She cannot tolerate tampon insertion or intercourse due to pain as well. She does not know when this started, but she did try to use a tampon at age 19 and was unsuccessful. Her boyfriend broke up with her 6 months into the relationship as she is unable to tolerate intercourse and in tears as she is anxious to have a pap smear.
Subjective:
Approach: As always I would approach the patient with kindness, empathy and take my time to allow her to feel comfortable. From start to finish I would over-communicate the procedure and the risks and benefits of the procedure as well.
Questions:
Do you have a history of cancer?
Do you have family history of cancer?
When did you first start your menses?

When was your LMP?
How long does your menses last and is it regular?
Do you have any vaginal discharge or inflammation?
Do you have any history of surgery?
Do you have a history of STIs?
Do you have a history of any other medical diagnosis?
Do you intake alcohol or tobacco?
Do you have a history of sexual abuse?
Have you had any traumatic event that you would like to talk about?
Do you have any allergies to anything?
Medications: Denies any use of medications currently
Allergies: Denies any known food, environmental or chemical allergies.
Social Hx: Denies tobacco intake. Denies recreational drug intake. Denies alcohol intake.

Exercise: Goes running daily x 60 minutes
Sexually: not sexually active at this time
Immunizations: Flu 11/2023, COVID 11/2022, Tdap 11/2015
Health maintenance:
                       Pap smear: Due today
ROS:
General: Anxious and sad due to the current situation of needing a pap and fears of speculum getting inserted
Cardiac: Denies chest pain, palpitations
Respiratory: Denies respiratory distress or cough
GU: complains of dyspareunia or upon attempt to insert tampon.
LMP: 6/15/2024
OB:G0P0
Objective:
VS BP 129/71 P. 79 R. 20 T. 97.9 F O2 room air 100% Wt 135 pounds, Ht 65 inches
General: Well developed, well-nourished, crying, anxious
Cardiac: Regular rate and rhythm. No murmurs, rubs or gallops.
Chest: No deformities of the chest wall. Lungs clear to auscultation bilaterally.
Breast: No redness, tenderness, inflammation, discharge or masses noted bilaterally to breasts. No lymph nodes, redness, tenderness, inflammation or masses felt to axilla, supraclavicular and infraclavicular spaces.
Abdomen: Soft, nontender, nondistended. No organomegaly.
OB: G0P0
Pelvic exam: No vaginal discharge or lesions seen. Attempted to insert speculum but Gayle was in a lot of pain. Unable to continue as Gayle complained of pain and discomfort.
Is a pap smear necessary for this patient? Why?
For USPTF guidelines, pap smear regardless of sexual activity or not should start at age 21. (USPTF, 2022) But due to Gayle’s absent personal and family history of cancer, no sexual activity and increased pain/anxiety/fears we can forgo the attempt for a pap smear until we can figure out the cause for pain/anxiety/fears.
Order:
Pelvic ultrasound to check for any concerns or abnormalities of Gayle’s pelvic structures that are causing pain.
Working diagnosis:
           Vaginismus N94.2
   “Involuntary tensing of vaginal muscles that result in pain with penetration” or “marked hypertonicity of overactivity of pelvic floor muscles with or without genital contact.” (Kellog & Kingsberg, 2024)
Patient is unable to have intercourse or complete a pap smear due to extreme discomfort during or an attempt of vaginal penetration
Differential Diagnosis:
           Vulvodynia N94.81
“pain in the vulvar area that has persisted for at least 3 months without a clear identifiable cause, is idiopathic pelvic or vulvar pain, or pain with penetrative sexual contact”. (Alexander, 2023)
Plan
Vaginismus N94.2
Ultrasound abdomen transvaginal to check for abnormal structures as probable cause for pain. Take Xanax 0.5mg one tab PO x 1 30mins prior to appointment time to relax her.
Refer to mental health provider to see if this is a psychosocial issue
Offer relaxation techniques
Refer to sex therapist
Offer PT for pelvic floor exercises
Refer to gynecology as well for vaginismus
Follow up in clinic in 3 months
POST 2 
Ty is a 22-year-old who comes to your office for an annual physical exam. On the intake paperwork, you noted that the gender box was blank. Ty was female assigned as birth but identifies as They/Them. The patient selected both the “have sex with females” and the “have sex with males” box in the sexual history.
Answer the following in complete sentences or question format as if you are asking the patient these questions:
How will you verify the patient’s name and preferred name?

Hello, I am the healthcare provider you will be seeing today.
Please confirm your full name and let me know if you have a preferred name you’d like me to use.
How will you ask for the patient’s gender?
I noticed the gender box was left blank on your intake form. How do you identify in terms of gender? I prefer not to specify, but I was born a female.
How will you ask for the patient’s preferred pronouns?
To ensure I address you correctly, please tell me which pronouns you prefer. // They/them
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?
Can you describe any symptoms or discomfort you have experienced recently? No, I haven’t felt any discomfort.
Have you noticed any changes in your menstrual cycle or sexual health? No changes my menstrual lasts 5 days and I get it usually every 30 days.
What other medical history questions should you ask?
Any recent surgeries or procedure? Nothing

Are you currently taking any medications, including hormones? No medications

What other family history questions should you ask?
Is there a history of breast or ovarian cancer in your family? Not that I am aware of
Does anyone in your immediate family have a history of cardiovascular disease? My mom has high blood pressure.

What other social history questions should you include?
Do you feel safe and supported in your current living situation and relationships? My family does not talk to me much except my mother. I am happy with my apartment and I have a good strong group of friends.

How would you describe your stress levels and coping mechanisms? Yoga has helped me a lot.

Objective:

Write a detailed, focused physical assessment of this patient.
Ty presents with normal ranges for vital signs and normal general systematic examination findings. With Ty’s permission, a breast check-up was conducted, and it did not show any breast mass or any abnormalities on check-ups; the external genitalia were normal female genitalia without any signs of infection or any lesion as spotted. During the pelvic examination, Ty has only complained of mild discomfort and muscle contraction, which can be a sign of vaginismus or concern regarding the pelvic examination.
Is a pap smear necessary for this patient? Why?
If Ty has a cervix and is 21 years or older, a Pap smear is required according to the current screening guidelines. While Ty is non-binary, their biology defines the cervical cancer screening requirement. Pap smear screening is relevant to a patient with a cervix and based on the physical body, not gender (Wentling et al., 2021). If Ty is not willing to undergo the procedure, explaining the self-swab HPV testing method and the pros and cons of the intended procedure is vital.

Explain what other test(s) you will order and perform, and discuss your rationale for ordering and performing each test.

Based on Ty’s age and his reported sexual history of getting to be with both men and women, thorough Sexually Transmitted Infections (STIs) testing should be done. Some of these should include HIV/AIDS, syphilize, and chlamydia should be evaluated. Also, evaluating Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) testing based on risk factors in the context of the disease is vital. A basic set of tests, which includes a complete blood count and metabolic panel, can give helpful information about the patient’s general health (Forny et al., 2021). Depending on the specific hormonal treatments Ty is taking, tests of hormone levels may be required. Finally, based on Ty’s family history and other risk factors, lipid panel and fasting glucose studies were ordered for cardiovascular risk factors and diabetes, respectively.
Assessment/ Diagnosis:
What is your presumptive diagnosis? Why?
The presumptive diagnosis for Ty is gender dysphoria because of her non-binary identity, but she is physically female. Therefore, this diagnosis is supported by Ty’s decision to enter ‘rather not state’ in gender on intake forms and their request for gender-neutral pronouns due to perceived sex and gender being incongruent; therefore, as this diagnosis may assist in finding Ty’s management.
Any other diagnosis or differential diagnosis you would like to add?

The other differential diagnosis that can be entertained is vaginismus. The condition vaginismus can present with mild discomfort and muscle tensing (Tetik et al., 2020). Also, because of Ty’s sexual history, which includes having had intercourse with both male and female partners, STI could present itself as a diagnosis; however, this would need to be tested to be determined.

Plan: 
What educational considerations should you include regarding having a male partner?
Safe practices include using condoms for protection.
Regularly screen for sexually transmitted infections.
What educational considerations should you include regarding having a female partner?

Use dental dams to prevent sexually transmitted infections.
Regularly screen for sexually transmitted infections.

Prevent infections through safe skin-to-skin contact.
Are there any treatments or medications you would prescribe and why?
Prescribe hormone therapy to address hormonal imbalances.

Consider flibanserin for low libido in females.
Explain treatment/management guidelines, including any possible side effects and considerations for managing the diagnosis.

Hormone therapy can cause mood changes and weight gain.
Flibanserin may cause dizziness, fatigue, and hypotension.
What patient education is important to include for this patient? (Consider including pharmacological, supplements, and nonpharmacological recommendations and education)

Adhere to medications and monitor for side effects.
Consider supplements like Vitamin D omega-3 fatty acids.

Engage in regular exercise and stress management.   
What is the follow-up plan of care?
Schedule follow-up to monitor treatment effectiveness.

Regularly assess sexual health and overall well-being.