First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 16. 28-Year-Old Woman with Pain During Sex

DOORWAY INFORMATION

Opening Scenario

Stephanie McCall, a 28-year-old female, comes to the office complaining of pain during sex.

Vital Signs

BP: 120/85 mm Hg Temp: 98.0°F (36.7°C)

RR: 13/minute

HR: 65/minute, regular

Examinee Tasks

1. Take a focused history.

2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).

3. Explain your clinical impression and workup plan to the patient.

4. Write the patient note after leaving the room.

Checklist/SP Sheet

Patient Description

Patient is a 28 yo F.

Notes for the SP

None.

Challenging Questions to Ask

When asked about vaginal discharge, ask, “Do you think I have a sexually transmitted disease?”

Sample Examinee Response

“There are many causes of vaginal discharge, only some of which are due to sexually transmitted infections. I will try to look for clues by asking you more questions and examining you, and we will definitely send a sample of the discharge to the lab to check for infection.”

Examinee Checklist

Building the Doctor-Patient Relationship Entrance

 Examinee knocked on the door before entering.

 Examinee introduced self by name.

 Examinee identified his/her role or position.

 Examinee correctly used patient’s name.

 Examinee made eye contact with the SP.

Reflective Listening

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.

 Examinee summarized the SP’s concerns, often using the SP’s own words.

Information Gathering

 Examinee elicited data efficiently and accurately.

Connecting with the Patient

 Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination

 Examinee washed his/her hands.

 Examinee asked permission to start the exam.

 Examinee used respectful draping.

 Examinee did not repeat painful maneuvers.

Closure

 Examinee discussed initial diagnostic impressions.

 Examinee discussed initial management plans:

□ Follow-up tests: Examinee mentioned the need for a pelvic exam.

 Examinee asked if the SP had any other questions or concerns.

Sample Closure

Ms. McCall, your most likely diagnosis is an infection in the vagina or cervix. However, there are other, less common causes of your problem. I can’t make a diagnosis until I do a pelvic exam and take a look at what I find under a microscope. I will also take a cervical swab and send it for gonorrhea and chlamydia testing. Do you have any questions for me?

History

HPI: 28 yo F c/o pain during intercourse for 3 months, located both superficially and with deep thrusting. She also noticed a scant white vaginal discharge with a fishy odor, accompanied by mild vaginal pruritus. She denies postcoital or intermenstrual vaginal bleeding. She is sexually active with her boyfriend (only) for the past year, and her sexual desire is normal. She feels safe at home and denies any conflicts with her partner. She also denies vaginal dryness, hot flashes, hirsutism, depression, fatigue, sleep problems, dysuria, and urinary frequency.

OB/GYN: G0P0. Last menstrual period 2 weeks ago; has regular menses but started to be painful over the past year No history of abnormal Pap smears; most recent was 6 months ago. Uses patch for contraception.

ROS: Negative except as above.

Allergies: NKDA.

Medications: None.

PMH: History of rape 10 years ago; subsequently contracted gonorrhea.

PSH: None.

SH: No tobacco. Drinks a couple of beers on the weekends, occasional wine, CAGE 0/4; used marijuana in college. Exercises regularly.

FH: Noncontributory.

Physical Examination

Patient is in no acute distress.

VS: WNL.

Chest: Clear breath sounds bilaterally.

Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.

Differential Diagnosis

CASE DISCUSSION

Patient Note Differential Diagnoses

 Vulvovaginitis: This describes infection or inflammation of the vagina. Etiologies include pathogens (eg, Gardnerella), allergic or contact reactions, and friction from intercourse. The presence of a vaginal discharge accompanied by a fishy odor and pruritus makes this the most likely diagnosis.

 Cervicitis: The presence of vaginal discharge and pain with deep thrusting suggests infection or inflammation of the cervix. Although the patient is in a monogamous relationship, she does not use barrier contraception and could still contract an STD if her partner were to acquire one.

 Endometriosis: This describes abnormal ectopic endometrial tissue, which can cause inflammation and scarring in the lower pelvis. Endometriosis may account for the patient’s dysmenorrhea over the past year and, if so, could also cause dyspareunia with deep thrusting.

Additional Differential Diagnoses

 Pelvic inflammatory disease (PID): The patient’s history of gonorrhea infection (if it caused PID) also puts her at risk for pelvic scarring and subsequent dyspareunia (due to impaired mobility of the pelvic organs).

 Vulvodynia: This is the leading cause of dyspareunia in premenopausal women but is not well understood.

Pain may be constant or intermittent, focal or diffuse, and superficial or deep. Physical findings are often absent, making it a diagnosis of exclusion. However, vulvar erythema can be seen in a subset of vulvodynia termed vulvar vestibulitis.

 Domestic violence: Physicians must screen for this in any woman presenting with dyspareunia. Serial screening is required, as victims may not disclose this history initially.

 Pelvic tumor: This could account for the patient’s pain with deep thrusting and possibly for her history of dysmenorrhea. However, pelvic tumors are not associated with vaginal discharge and pruritus.

 Vaginismus: This describes severe involuntary spasm of muscles around the introitus and often results from fear, pain, or sexual or psychological trauma. The muscle contractions generally preclude penetration. Although this patient was raped in the past, she does not describe the muscle contractions characteristic of vaginismus.

Diagnostic Workup

 Pelvic exam: To localize and reproduce the pain or discomfort and to determine if any pathology is present. A complete exam includes external genital inspection and palpation, a speculum exam, and bimanual and rectal exams.

 Wet mount, KOH prep, "whiff test": The vaginal discharge is examined microscopically. The presence of epithelial cells covered with bacteria (clue cells) suggests bacterial vaginosis, and the presence of hyphae and spores indicates candidal infection. Motile organisms are seen in trichomonal infection. A “fishy” odor following exposure of the discharge to a drop of potassium hydroxide is characteristic of bacterial vaginosis.

 Cervical cultures: To diagnose chlamydia, gonorrhea, and occasionally HSV infection (the latter is characterized by the presence of vesicles or ulcers on the cervix).

 Laparoscopy: The gold standard for confirming a clinical diagnosis of endometriosis or scarring of the pelvic organs from prior infections or surgeries.

 U/S—pelvis: Can be used to assess the size and positioning of pelvic organs and to help rule out masses or other pathology.



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