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G33003 white female presenting for her initial gynecologic visit today, 4/2/2025, with complaints of hot flashes
MB is a 54-year-old G33003 white female presenting for her initial gynecologic visit today, 4/2/2025, with complaints of hot flashes and cramping; She is postmenopausal and on
progesterone 100 mg oral daily for vasomotor symptoms,
estradiol 0.0025 mg/day transdermal patch, and
testosterone 2 mg/gm topical cream daily. She reports bothersome
cramping associated with the estradiol patch. No current abnormal vaginal bleeding, discharge, or pelvic pain. No urinary complaints. Breast exam concerns negative. She had
breast implants placed in 2019.
She is a
university professor at NYU and reports high stress following the
death of her husband one year ago. She is not currently sexually active but consents to STI screening as part of routine care.
Family history is significant for:
·
Maternal grandmother with
breast cancer
·
Maternal aunt with
uterine cancer
Vitals: BP 126/78, HR 76,wt 152 lbs
Well-appearing, NAD.
Pelvic exam: External genitalia normal. Vaginal mucosa mildly atrophic. Cervix normal. Uterus small, mobile, nontender. Adnexa nontender.
Breast exam: Bilateral implants in place, no tenderness, masses, or nipple discharge. Skin intact.
GC/CT swab collected today.
Assessment/Plan:
54-year-old postmenopausal G3P3 female on hormone therapy with cramping likely related to estradiol patch; significant family history of breast and uterine cancer.
Discontinue estradiol 0.0025 mg/day patch.
Start
Climara 0.025 mg patch, apply 1 patch weekly.
Continue
progesterone 100 mg daily for endometrial protection.
Continue
testosterone 2 mg/gm cream daily.
STI screening: GC/CT swab sent today.
Breast implants intact; exam benign. Recommend
annual mammogram.
Family history of breast and uterine CA discussed—
referral to genetic counseling placed.
Discussed grief support and emotional well-being; offered referral to therapist, patient declined at this time.
Return in 3 months to reassess hormone regimen and symptoms.
This is just a sample; don’t use these medications. NOTE:
Pharmacology interventions MUST BE IN THIS FORMAT
Ciprofloxacin (Cipro) 500 mg tablet orally every 12hrs for seven days
Acetaminophen 650 mg tablet orally every 4-6 hours as needed.
Ondansetron (Zofran) 8 mg tablet orally every 12 hours as needed for seven days.
APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2020-2025 only. (Within the last five years)
Please do not solely use a website as your scholarly reference. It is fine to use it as a supplement, but a journal article or text should be referenced.
Please use North American peer-reviewed journals ONLY.
DO NOT use any European Journal
Please use reliable medical references such as the Current Medical Diagnosis and Treatment book or UpToDate. Do not use WebMD, Wikipedia, etc., as these are not advanced practice references.
APA format (if using outside sources)..
1. Three Differential Diagnoses:
( first one must be the primary diagnosis)
2. Pathophysiology for Diagnosis
(each diagnosis) with etiology
3. Pertinence of Research Article
(for primary diagnosis)
4. Plan of Care: Testing/Studies:
5. Pharmacological:
6. NONPHARMACOLOGIC METHODS SHOULD BE DISCUSSED ALSO
7. Patient Education:
8. Follow up:.
9.
Use the rubric attached.
10.
specifically focusing on gynecological (OBGYN) cases.
Directions:
submission should be based on actual clinical experiences and must highlight a GYN-related diagnosis, assessment, and management plan.
The case study should include a clear presentation of the patient’s chief complaint, relevant medical history, physical examination findings, diagnosis, and a comprehensive management plan, including both pharmacological and non-pharmacological interventions. Additionally, you should provide a detailed explanation of the patient education you provided, focusing on the condition, treatment plan, and any lifestyle modifications or follow-up care.
Lastly, reflect on the challenges and learning experiences from the case.
study is well-organized, incorporates clinical guidelines, and follows any formatting and referencing requirements as outlined in the course syllabus.
This is just a sample; don’t use these medications. NOTE:
Pharmacology interventions MUST BE IN THIS FORMAT
Ciprofloxacin (Cipro) 500 mg tablet orally every 12hrs for seven days
Acetaminophen 650 mg tablet orally every 4-6 hours as needed.
Ondansetron (Zofran) 8 mg tablet orally every 12 hours as needed for seven days.
APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2020-2025 only. (Within the last five years)
Please do not solely use a website as your scholarly reference. It is fine to use it as a supplement, but a journal article or text should be referenced.
Please use North American peer-reviewed journals ONLY.
DO NOT use any European Journal..
Please use reliable medical references such as the Current Medical Diagnosis and Treatment book or UpToDate. Do not use WebMD, Wikipedia, etc., as these are not advanced practice references.
APA format (if using outside sources). –.
Criteria
Ratings
Pts
This criterion is linked to a Learning Outcome Chief Complaint
3 pts
Excellent
Clearly and concisely states the chief complaint
1.
8 pts
Good
Partially states or unclear information
0 pts
Needs Improvement
Missing or incorrect information
This criterion is linked to a Learning Outcome History of Present Illness (HPI)
8 pts
Excellent
Thorough and detailed HPI
4.8 pts
Good
HPI is adequate but lacks detail
0 pts
Needs Improvement
Minimal or missing HPI
This criterion is linked to a Learning Outcome pertinent Past Medical History
4 pts
Excellent
Comprehensive PMH including OB/GYN history
2.4 pts
Good
Basic PMH without all necessary details
0 pts
Needs Improvement
Incomplete or missing PMH
This criterion is linked to a Learning Outcome Review of Systems (ROS)
8 pts
Excellent
Complete and thorough ROS
4.8 pts
Good
Partial or missing systems
0 pts
Needs Improvement
Missing ROS
8 pts
This criterion is linked to a Learning Outcome Family & Social History (FH/SH)
2 pts
Excellent
Complete and relevant FH/SH
1.2 pts
Good
Incomplete or irrelevant FH/SH
0 pts
Needs Improvement
Missing FH/SH
This criterion is linked to a Learning Outcome Physical Exam: Including In-Office Diagnostics
20 pts
Excellent
All appropriate systems examined with proper techniques
12 pts
Good
Some systems examined, but lacks thoroughness
0 pts
Needs Improvement
Incomplete or missing exam
This criterion is linked to a Learning Outcome Differential Diagnoses 1: Working Diagnosis
10 pts
Excellent
Three clear diagnoses with solid rationales. Including pertinent positives and negatives.
6 pts
Good
Two diagnoses or partial rationales
0 pts
Needs Improvement
One or no diagnoses
This criterion is linked to a Learning Outcome Differential Diagnoses 2
5 pts
Excellent
Working diagnosis defined with pathophysiologic support. Including pertinent positives and negatives.
3 pts
Good
Some definitions unclear or missing rationale
0 pts
Needs Improvement
Minimal or missing definitions
This criterion is linked to a Learning Outcome Differential Diagnoses 3
5 pts
Excellent
One research article and two OB/GYN references used effectively. Including pertinent positives and negatives.
3 pts
Good
Partial or missing references
0 pts
Needs Improvement
No references used
5 pts
This criterion is linked to a Learning Outcome Plan of Care: Diagnostic Testing/Studies
4 pts
Excellent
Clear, appropriate tests/studies
2.4 pts
Good
No relevant testing
0 pts
Needs Improvement
No references used
4 pts
This criterion is linked to a Learning Outcome Plan of Care: Pharmacologic Treatment
5 pts
Excellent
Clear prescription in appropriate language
3 pts
Good
Partial or unclear prescriptions
0 pts
Needs Improvement
Missing or incorrect pharmacology
5 pts
This criterion is linked to a Learning Outcome Plan of Care: Patient Education
9 pts
Excellent
Comprehensive, including non-pharmacologic education
5.4 pts
Good
Partial or minimal education
0 pts
Needs Improvement
Missing education
This criterion is linked to a Learning Outcome Plan of Care: Follow-Up
2 pts
Excellent
Clear and appropriate follow-up plan
1.2 pts
Good
Follow-up plan lacks detail
0 pts
Needs Improvement
No follow-up plan
2 pts
This criterion is linked to a Learning Outcome Research Article and 2 OB/GYN references: Neatness, Format, Terminology
15 pts
Excellent
Neat, typed, submitted on time, proper format
9 pts
Good
Some errors in presentation or format
0 pts
Needs Improvement
Disorganized or incorrect format
Total Points: 100
LPH 11/11/2010
1 | P a g e
WOMEN’S HEALTH CASE STUDIES – GUIDE
HISTORY
S: CC: Use pt’s words in quotation marks
HPI: Include onset, duration, progression, timing, amount, aggravating factors, alleviating factors, treatments already tried, previous h/o similar S&S? Fully describe, e.g. pelvic pain, noting relationship in time with menstrual cycle, association with sex, tampon use, or other factors. Describe any vaginal bleeding not associated with menses. Include pertinent negatives.
OB/Gyn History:
Menstrual history: LMP, age at menarche, length of cycle, average number of days of menses, characteristics of flow, regularity of cycles, descriptions of any irregularities and/or accompanying symptoms. (Normal cycle: 21 – 35 days, menses last 4 – 7 days)
Pregnancy history: GTPAL. Chronological order: year, duration, type of birth, sex, baby’s weight, complications, is the child alive and well? TABs, SABs, ectopics, molar pregnancies.
History of STIs: what type of infections, what tx, how frequently, complications? & screen for HIV risk. Number of current sexual partners and lifetime, condom use? Does she
douche?
Gyn problems/procedures:
Breast biopsies?
Paps: Date of last, Abnormals?, if so – Follow ups? HPV results?
Colposcopy’s, LEEP, etc…
Contraceptive use: is she currently using a method? Is she satisfied with it or does she desire a change? Discuss her past methods if relevant for the visit.
Menopause or peri-menopause: if appropriate to age – HRT?, non-pharmacologic therapies?
Social History/Habits: Include use of tobacco, drugs, ETOH, Current living situation. Occupational, exposure to hazards. Relationships, recent sexual history/partners, monogamous?
Chart Review: Relevant information from chart, place either in S or O
General Medical History: Include any pertaining to the CC or that would affect treatment plan
Current illnesses or disease
Past hospitalizations or serious injuries
Prior surgical procedures
Immunization status Tdap? HPV? Etc…
Medications: OTC, herbal, prescriptions
Allergies: meds, environmental, latex, shellfish, iodine
FMH: Include any pertinent to the CC or that would affect treatment plan (alcoholism, cancer, endocrine, genetic/chromosomal, hematological, mental retardation, CVD, congenital anomalies, GI, lung, neuro, renal, multiple gestation, DV). Brief
Chart Review: Relevant information from chart, place either in S or O
________________________________________________________________________
ROS – as per your prior case studies with emphasis on Breast and GU
For ex – Denies breast tenderness, nipple discharge or noted changes in breast, does not perform monthly BSE etc…
________________________________________________________________________
PHYSICAL EXAM = BULLET FORMAT in head to toe order!
PE: Include only systems r/to CC. Organize by systems and list in head to toe order. Sometimes no exam is necessary, and this should be noted (e.g., “deferred, not examined”) however do not do a case study on a patient who does not require a reproductive health exam. A breast, pelvic, and or OB exam is REQUIRED.
O: Vital signs, weight, height, BMI
General: Observation of pt – is she anxious, nervous, in pain? If so, identify the behaviors she demonstrates. Does she look older than stated age? State of health (ex: malnourished, well-nourished, obese)? Can use NAD
HEENT: Normocephalic. EOMI. PERRLA. TMs pearly gray bilaterally. No nasal drainage or lesions. Mouth and throat without lesions or exudates, teeth in good repair, gums pink.
Neck: No lymphadenopathy or thyroid enlargement, no masses palpated
(thyroid dysfunction can cause irregular menses, anovulation, and infertility)
Cardiac: RRR, no murmur, S1S2
Chest/Lungs: CTAB No wheezes, rales, rhonchi
Breast exam: Size (if remarkable, e.g. small, large, pendulous), nipples, symmetry. Skin changes (rashes, lesions, dimpling, retraction). Note masses, lumps, or tenderness. Description of a mass: Location (can draw picture or describe location as on a clock face), size, shape, consistency, mobility distinctness, nipple, skin over lump, tenderness, lymphadenopathy.
(Ex: No masses, lumps, or tenderness palpated, symmetrical without nipple discharge. Axilla without palpated masses or lymphadenopathy etc)
Abdomen: Non-tender, no hepatosplenomegaly, scars, striae, if pregnant (or postpartum) fundal height etc..
Pelvic exam:
External Genitalia: Mons including hair distribution ( no lesions, shaved), labia majora and minora, clitoris, Bartholin’s and Skene’s glands (often grouped with urethra as BUS), hymen, introitus, perineum. Piercings?
Please do not state “intact” – not appropriate terminology here
Vagina: Color, rugation, odor, tone, discharge. (Cystocele, rectocele, discharge, inflammation, lesions, masses) (Ex: rugated, pink, no lesions or discharge, good tone)
Cervix: Color, os, position, texture, mobility. (Lesions, masses, inflammation, discharge, friability or bleeding, cervical motion tenderness/CMT) (Ex: No CMT, lesions, ectropion, discharge, patent os) Again, not “intact”
Uterus: Position, size, consistency, mobility. (Masses or tenderness) (Ex: Small, firm, midline, smooth and mobile, non-tender)
Adnexae: Size & shape. (Masses or tenderness) (Ex: bilaterally nontender, no masses palpated)
Extremities: FROM no varicosities, or edema
Diagnostics: List results that you
already have available (lab, x-ray, urine dip, office pregnancy test, sono report etc..)
DIFFERENTIAL DIAGNOSES
WORKING DIAGNOSIS ALWAYS FIRST
A: #1 Diagnosis: (WORKING DIAGNOSIS) FOR EX:
Undesired fertility (for gyn/birth control visit)
Prenatal visit at 32 weeks gestation
Vulvovaginal Candidiasis etc….
Cervicitis
Pathophysiologic support for your working diagnosis WITH pertinent positives and negatives
#2,3 List and explain your differential’s (diagnosis’) – you should
have 2 additional DD’s related to your working diagnosis – list pertinent positives and negatives
“what else could it be?” with
brief patho here
(you may have other diagnoses as well just list them– for ex: )
• contraceptive management
• high risk sexual behaviors
• IUP @ 28 weeks etc….
• Whatever…
PLAN OF CARE
P: Diagnostic (lab, x-ray, cultures) that you plan to do for this patient for this pt (Ex: Pap smear, GC/CT)
Pharmacologic Treatment (including OTC, herbals, prescription) Correct dosing and directions as you would write a prescription –
(For ex: Diflucan 150mg po x1 dose today – dispense #1, no refills)
Education (Ex: nutrition, exercise, calcium intake; BSE)
Follow-up: Must state when the pt will be seen again. (Ex: RTC in 1 yr for annual exam and prn or Return to office in 3 months for contraceptive management)
Consultations, Collaborations, or Referrals
You must include one Research Article and 2 References
HISTORY
S: CC:
“1 am here for a postpartum checkup.”
HPI:
AU is a 27 y/o African American female who presented to the clinic today for a postpartum visit. She had a full-term vaginal delivery with episiotomy on 07/02/2024. She is currently breast-feeding but wishes to switch to bottle-feeding. She denies any breast engorgement and low breast milk. She reports and describes pain as five on the pain scale of 10 at the episiotomy site. She takes Ibuprofen with some relief. She has whitish yellowish vaginal discharge. She denies any spotting, vaginal bleeding, or swelling. She is married and has not started post-delivery sexual activities.
A chaperone was present during this exam and consultation.
OB/Gyn History
:
Menstrual history: LMP 10/01/2023, Menarche at 10 years old, Her menstrual cycle was regular q29d and 3-5 days menstrual days before pregnancy.
She noticed increased menstrual cramps before and during her menstruation. Increased volume of menstrual blood sometimes with minute clots, and she changes up to 7 pads per day.
Pregnancy history:
G1T1P0A0L1. The 1 pregnancy was full term vaginal delivery at 40 weeks without complications. The delivery was a boy. The baby’s weight was 7lbs 8oz
History of STIs:
AU denies any history of STDs. She is married and sexually active with husband. AU is not sexually active due to recent delivery. Currently, has 1 sexual partner. Last STIs was negative. She does not douche or use condom during sexual intercourse with husband.
Gyn problems/procedures:
Last Pap smear in 2023 was normal. Denies prior STDs, dyspareunia, vaginal discharge, post coital bleeding or spotting in between periods.
Contraceptive use: No contraceptive.
Menopause or peri-menopause: Denies any peri- or menopausal symptoms.
Social History/Habits: AU is a stay at home wife/mom. Denies drinking, use of
illicit drugs and smoking. She is married, monogamous and was sexually active
with husband before recent delivery. Denies any history of STDs.
Current illnesses or disease: pain at the episiotomy site, last Pap smear was in 2023 and normal, denies prior STD, dyspareunia, vaginal discharge, post coital bleeding or spotting in between periods.
Past hospitalizations or serious injuries: Denies past hospitalizations or serious
Injuries.
Prior surgical procedures: Denies any prior surgical procedures.
Immunization status: age appropriate immunization up to date as per immunization registry and patient.
Medications: Ibuprofen 400mg PRN
Allergies: No Known Allergies (NKA)
FMH: Paternal history unknown. Mother has diabetes, and brother has HTN and diabetes. Denies any known familial history of ovarian, endometrial, and uterine abnormalities or cancer.
Chart Review: Relevant information from chart, place either in S or O
ROS
General: Appears well-groomed, walked into exam room with no abnormalities detected
Skin: normal with no lesions or abnormalities noted.
Head, Eyes, Ears, Nose, Throat (HEENT):
Head: No history of head injury.
Eyes: No reading glasses, vision good. Ears: Hearing good. No tinnitus, vertigo, infections.
Nose / Sinus: No hay fever, sinus trouble. Throat: No tooth pain or gum bleeding.
Neck: No mass, goiter, pain. No swollen glands.
Breast: No mass, no pain.
Respiratory: No cough, wheezing, shortness of breath.
Cardiovascular: No dyspnea, orthopnea, chest pain, and palpitations.
Gastrointestinal: Patient denies any nausea, vomiting, indigestion, constipation, diarrhea or bleeding, liver problems, and pain.
Urinary: No frequency, dysuria, hematuria, or recent flank pain.
Genital: No vaginal or pelvic infections. No dyspareunia.
Peripheral Vascular: No history of phlebitis or leg pain.
Musculoskeletal: experiences occasional body aches.
Psychiatric: Denies any history of depression and treatment of depression
Neurological: No focal neurological deficits. No fainting, seizures, motor or sensory loss. No memory problems.
Hematologic: No easy bleeding or bruising.
Endocrine: No known heat or cold intolerance. No Polyuria, Polydipsia.
O: Vital signs
: TEMP: 97.0F, RR; 17 beats/min, HR 71 beats/min, B/P: 127/69, WT: 168lbs, HT 5′ 6ft, BMI 27.1.
General: AU is alert and oriented X4 and very cooperative, hair well groomed, well nourished, speech is clear good tone. Gait is steady, and appears appropriate for age as stated.
Skin: No rashes to the abdomen or face. Skin warm to touch, cap refill <2seconds without clubbing or cyanosis.
Hair: even distribution, thick texture, and no lesions.
Head, Eyes, Ears, Nose, Throat (HEENT):
Head: is normocephalic and atraumatic, Hair evenly distributed with average texture. No hair loss noted.
Eyes: conjunctiva pink and sclera are white.
Neck: Neck is symmetrical in appearance. No lumps noted in the head, axillae. No goiter noted. No masses palpated on thyroid. Good ROM. Denies any difficulty or pain with swallowing.
Lymph nodes: No lymphadenopathy noted. No regional lymphadenopathy to the axillary, supraclavicular, parasternal and infraclavicular.
Cardiovascular: warm to touch, brachial pulses, and femoral pulses palpable. Normal S1 and S2 with no murmur rub or gallop, no heaves, or thrills.
PMI is non-displaced and located at 5th intercostal space.
Pedal and radial pulses 2+ equal bilaterally. JVD negative, no bruits over carotid
Capillary refill less than 2 seconds. No peripheral edema to lower and upper extremities. No edema to the limbs. Dorsalis pedis pulse, posterior tibial pulses, and popliteal pulses palpable. Calves are non-tender and not swollen.
Chest and lungs: Thorax elliptical in shape. No retractions or use of accessory muscles. No crepitus during palpation. Lung expansion bilateral. appropriate fremitus vibrations throughout, resonance on percussion. During auscultations no adventitious sounds noted. No rhonchi, rales, wheezing, retraction, or distress and no SOB.
Breast exam:
The skin warm to touch. No bilateral breast pains. No swelling, redness or edema noted. No lumps, masses, rashes or lesion. Symmetrical in size during the inspection, no retractions, dimple or creases noted bilaterally. Breast milk discharge noted with mild palpation around the areola.
Abdomen: Bowel sounds + in all four quadrants. Abdomen soft and non-tender. No rebounding or guarding noted during the examination. Mild Diastasis Recti at 1-2 finger widths.
Pelvic exam:
External Genitalia: Hair distribution of normal female pattern, no rashes no lesions, irritation or piercing. Mild bruising noted.
Vagina: Vaginal mucosa pink, rugae present with lochia alba noted. Slight erythema and edema noted. Episiotomy with sutures intact noted.
Cervix: at posterior with noble mobility, Cervical os is at 2cm consistent birth with lochia alba. No bleeding, inflammation and polyps.
Uterus: midline, uterus mobile, soft, nontender, no palpable mass. Slightly enlarged due to recent childbirth.
Adnexae: No adnexal tenderness or masses bilateral.
Rectal: No external hemorrhoids noted
Extremities: No varicosities, no edema. Good muscle bulk and tone. Strength is 5/5, normal reflexes 2+.
Diagnostics:
Specimens: Urinalysis – no leukocytes, protein or glucose
Pap smear was normal in 2023.
DIFFERENTIAL DIAGNOSES
A: #1 Diagnosis
–
Prolonged Episiotomy Healing (PEH)
Pathophysiologic
PEH occurs when the normal process of tissue repair is delayed due to various physiological or external factors. After an episiotomy, the body initiates an inflammatory response to remove damaged tissues and prevent infection. This phase typically lasts a few days. If this inflammatory phase is prolonged, possibly due to infection, excessive tissue damage, or foreign bodies (such as retained sutures), the healing process is delayed. Persistent inflammation can lead to ongoing pain, redness, and swelling.
Pertinent Positives Supporting the Diagnosis: AU complained of
1. Pain at Episiotomy Site: Suggests potential issues with healing pointing
towards a potential delayed healing.
2. Whitish-Yellowish Vaginal Discharge: Could indicate lochia, normal
postpartum discharge, possibly vaginitis, or endometritis. Needs to be
differentiated between normal lochia alba and infection.
3. Mild Erythema and Edema at Episiotomy Site: Erythema and edema could
indicate an inflammatory response, which might be due to infection or delayed
healing. Supports the possibility of a localized infection or irritation at the
healing site.
4. Mild Bruising Noted in the External Genitalia: Bruising is a common
finding after episiotomy and delivery, but persistence may indicate delayed
healing. Supports the likelihood of ongoing inflammation or slow healing.
Pertinent Negatives Supporting the Diagnosis: AU denies and had
1. No Fever: The absence of fever decreases the likelihood of a systemic
infection like endometritis. Suggests that, if there is an infection, it might be
localized rather than systemic.
2. No Foul-Smelling Discharge: Foul-smelling discharge is often associated
with infections like endometritis or bacterial vaginosis. Reduces the likelihood
of a significant infection in the uterus or vagina.
3. No Swelling or Masses Noted at Episiotomy Site: Lack of swelling or a
palpable mass makes conditions like hematoma or abscess less likely.
Suggests the issue may be related more to inflammation or infection rather
than a structural complication.
4. No Vaginal Bleeding or Spotting: Persistent or recurrent vaginal bleeding
could indicate subinvolution of the uterus or retained products of conception.
The absence of bleeding makes these diagnoses less likely.
5. Normal Vital Signs (Afebrile, Stable BP, HR): Stable vital signs indicate
the patient is not in acute distress and is less likely to have a serious systemic
infection. Further supports a more localized issue rather than a systemic
problem.
Based on the pathophysiologic understanding of PEH and the patient’s symptomatology PEH is the most likely diagnosis.
#2 Diagnosis –
Inflammatory Pain
Pathophysiologic
The pain associated with prolonged episiotomy healing is due to several
underlying pathophysiological processes that prolong the normal wound healing
stages and exacerbate discomfort. Normally, the inflammatory phase of wound
healing lasts a few days, during which immune cells release cytokines and other
inflammatory mediators to clear debris and initiate repair. Prolonged
inflammation leads to the continued release of pro-inflammatory cytokines and
other mediators like prostaglandins. These substances sensitize nociceptors – pain
receptors in the surrounding tissue, resulting in persistent pain and tenderness at
the wound site.
Pertinent Positives Supporting the Diagnosis: AU complained of pain at
episiotomy site rated 5/10 showing an ongoing discomfort and wound healing
issues. The presence of this whitish yellowish vaginal discharge can suggest an
underlying infection or inflammation at the wound site, which could be
contributing to the pain. A slightly enlarged uterus is normal
postpartum, but it might also indicate ongoing involution, which
could be contributing to discomfort.
Pertinent Negatives Supporting the Diagnosis: AU denies and had
No dyspareunia because she had not yet resumed sexual activity, so there’s no
evidence of pain during intercourse, which could indicate more extensive pelvic
floor dysfunction or severe scarring. Absence of muscle tightness on examination
reduces the likelihood of pain.
#3
Diagnosis
– Infection: .
Pathophysiologic
An episiotomy can serve as an entry point for bacteria, particularly if the wound is
exposed to perineal contamination from fecal material, vaginal secretions, or
improper wound care.These pathogens are part of the normal flora of the
perineum but can become pathogenic when the skin barrier is broken. Upon
bacterial invasion, the body’s immune system activates an inflammatory response.
Neutrophils are the first responders, migrating to the site of infection and
releasing cytokines and chemokines. These signals attract more immune cells,
including macrophages, to help fight the infection. The release of inflammatory
mediators (e.g., prostaglandins, histamines) increases vascular permeability,
leading to localized swelling, redness, and pain. These symptoms are typical signs
of infection and contribute to patient discomfort.
Pertinent Positives Supporting the Diagnosis:
The combination of whitish-yellowish vaginal discharge, pain, erythema, edema,
and mild bruising at the episiotomy site strongly aligns with the diagnosis of
endometriosis.
Pertinent Negatives Supporting the Diagnosis:
The absence of fever, foul odor from the vaginal discharge, no spotting or vaginal bleeding, urinary symptoms, and normal vital signs.
Other Possible Diagnoses
1. Episiotomy Dehiscence: Dehiscence can occur without signs of infection but often presents with localized pain and discomfort.
2. Hematoma Formation: Hematomas can cause significant pain and pressure, potentially delaying wound healing.
3. Scar Tissue Formation/Granulation Tissue: This condition may lead to chronic discomfort and pain, especially during activities that stretch the perineum.
4. Nerve Entrapment or Neuropathy: Neuropathic pain is often resistant to standard pain relief measures and may require specific treatments.
5. Urinary Tract Infection (UTI): While primarily presenting with urinary symptoms, a UTI could contribute to overall pelvic discomfort.
PLAN OF CARE
P: Diagnostic
None required at this time.
Laboratory Tests: CBC – Check leucocytes
Pharmacologic Treatment
Continue ibuprofen or consider prescribing acetaminophen as needed for pain management. Consider Topical Analgesics to provide localized pain relief.
Non pharmacologic – warm and cold compress
Education
Encourage a balanced diet of vegetables, fruits, and whole grains and to maintain overall health. Provide reassurance and emotional support, as prolonged healing can be distressing. Address any concerns about sexual activity or body image. Discuss contraceptive options post-delivery and how they may impact future pregnancies and delivery. Educate the patient on the signs and symptoms of worsening infection (e.g., increased pain, fever, foul-smelling discharge) and when to seek medical attention. Encourage adequate hydration and a balanced diet to support overall healing and immune function.
Follow-up:
Patient was invited for a follow up in 2 weeks to review the results of blood work results and assess the episiotomy site.
References
Barjon, K., & Mahdy, H. (2023) Episiotomy.
StatPearls.
https://www.ncbi.nlm.nih.gov/books/NBK546675/
Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery (2016).
Obstetrics & Gynecology. 128(1):p e1-e15,
DOI: 10.1097/AOG.0000000000001523
