1.Case Scenario 1
Table 1
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Term |
Definition |
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Sex |
Is based on the person’s sexual desire, identity, and presentation of one’s self. A woman’s sexuality can be expressed through a wide range of behavior through fantasy, self-stimulation, self-pleasure and communication about needs and desires. |
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Sexual health |
Is the ongoing process of physical, psychological and sociocultural well-being and is evidenced in the free and responsible expression of sexual capabilities that foster harmonious personal and social wellness, enriching individual and social life. |
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Sexual identity |
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Sexual orientation |
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Sexual agency |
Possession or control of one’s body |
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Applied as birth as male or female based on physical appearance of the external genitalia |
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Gender Identity |
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Transgender |
Identify that does not correspond to the sex they were assigned at birth |
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Gender dysphoria |
Incongruence between assigned sex and gender identity |
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Cisgender |
Individual whom biologic and expressed gender are the same |
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Transmale |
Biologic male expresses their gender as female |
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Transfemale |
Biologic female expresses their gender as male |
Table 2
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Name 5 medical (physical) causes of female sexual dysfunction |
Neurologic problems, Cardiovascular disease, cancer, urogenital disorders, hormonal loss |
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Name 5 medication-induced sexual dysfunction |
Antipsychotics, antihypertensives, antidepressants, antiandrogens, narcotics |
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Name 5 psychological cases of female sexual dysfunction |
Partner’s health status or sexual dysfunctionRelationship factors such as poor communication or discrepancies between partners’ desire for sexual activityIndividual vulnerability–sexual or emotional abuse, or poor body imageCulture or religious factorMedical factors | |
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Name at least 4 management plan to help with sexual dysfunction (include 2 pharmacologic and 2 non pharmacologic interventions) |
CovaryxTestosterone gelSelf-management by educating women about normal anatomy, sexual function and normal changes of aging, pregnancy and menopause.Cognitive therapy |
Table 3
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Define Vulvodynia–constant burning pain involving much of the vulva and often including the vestibule |
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Define Vaginismus-recurrent or persistent involuntary spasm of the musculature of they outer third of the vagina that interferes with vaginal penetration, causing personal distress |
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What is the difference between the 2 diagnoses? Vulvodynia is constant burning pain at the vulva for at least 3 month duration as for vaginismus is pain triggered by intercourse. |
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What are treatment options? Cognitive therapy or the use of herbal remedies such as Zestra |
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.
- Subjective: How will you approach this patient?As a clinician it is important to approach it by allowing the patient to tell their story and to make sure that the patient feels heard. What other relevant questions should you ask regarding the HPI?O- When did the pain start?L- When do you experience pain? Where do you feel the pain most?D- Is the pain consistent? Or does it come and go? Does the pain happen only during penetration? Or do you experience pain whenever something is being inserted such as a tampon?C-Can you describe the pain? On a scale of 1 to 10 as 10 being most painful, can you rate your pain? Is it constant or intermittent pain?A- What makes the pain worse? Does the pain happen before insertion or during deep penetration?R-Where is the pain and does it radiate elsewhere?T-Do you take any medication to help with the pain?
- What other medical history questions should you ask?
Do you have any past medical history? Any history of sexually transmitted infection? Do you have any surgical history?Any allergies?Do you currently take any medication? Any herbal supplements? Are you on any contraceptive treatment? Have you used any OTC topical treatments such as antifungal cream in your vagina?When was your last pap smear? Any history of HPV?Do you smoke?Do you drink alcohol? How often?Any usage of illicit drugs?What type of diet do you follow at home? What do you normally eat in a day? Do you enjoy a lot of sugary food? What do you do for a living?Are currently sexually active? How many partners have you had within the last 12 months?Any sexual trauma or abuse?What other social history questions should you include? What potential situation should you address or be suspicious of? Intimate Partner Sexual Violence questionsHave you ever been intimate with your partner when you didn’t want to?Does your partner ever force you to be intimate? How often does it happen?Are there times when sex between you and your partner is unpleasant? What happens to make it unpleasant?Have you ever had sex with your partner because they have threatened, pressured, forced or hurt you? What happened?What other family history questions should you ask?Any family history of vulvar pain? Any Ovarian, Cervical or Endometrial cancer in the family?How does your family perceive sex? Does your family have any culture or spiritual beliefs about having sexual intercourse? How do you feel about having sexual intercourse?
REVIEW OF SYSTEMS:
General: Any malaise or fatigue?
GI: Any nausea, vomiting or abdominal discomfort?
Genitourinary: When was your last menstrual period? At what age did you first start your period? How many partners have you had in the past 12 months? Has there been any change in your sexual desire or frequency of sexual activity? What type of sexual activities do you participate in? Any history of sexually transmitted infection? What method do you use for contraception? Do you ever have pain during intercourse? Do you use any lubricant or sexual devices to enhance sexual pleasure? Do you experience pain when urinating? Any urinary urgency or frequency? Any flank pain? Any episode of urinary incontinence? Any vaginal itching or discomfort? Any vaginal discharge?
Psychiatric/Mental Status: Any history of depression or anxiety? Any difficulty sleeping, persistent thoughts or worries? Any abnormal thoughts?
Objective: Write a detailed focused physical assessment on this patient. PHYSICAL ASSESSMENTGenitourinaryPalpate for any suprapubic tenderness or bladder bulges. Palpate for any costovertebral tenderness.Inspect the mons pubis, labia minora and majora, clitoris, urethra, Skene’s gland, Bartholin gland, perineum and anus. Inspect for any lesion, ulceration, abrasion or erythema.Palpate by performing a point pressure testing, by using a cotton swab, map the location and severity of the pain around the vulvar vestibule. Identify trigger points or tenderness. Bimanual exam– may use 1 or 2 digits within the vagina to assess the uterus, adnexa and uterosacral ligaments. Is a pap smear necessary for this patient? Why?According to Iglesia (2024), when performing a speculum exam, a smallest speculum should be used enough to adequately visualize the vaginal wall and cervix. We also want to assess for vaginal pallor or any vaginal discharge. However if the patient is anxious or uncomfortable a speculum examination is not necessary at this time to avoid any psychological triggers or trauma. A vaginal swab can be performed without the need of inserting a speculum when testing for bacterial vaginosis. If we suspect a sexually transmitted infection such as chlamydia or gonorrhea, a urine test can be performed.Explain what other test(s) you will order and perform, and discuss your rationale for ordering and performing each test. Perform sexually transmitted infection testing for chlamydia, gonorrhea or urinary tract infectionUA–Nucleic Amplification Acid testUA C/SSyphilis testRapid plasma reagin test
***According to Iglesia (2024), we would want to test and eliminate possible causes of vaginal pain. Common vaginal pain is caused by vaginal infections such as bacterial vaginosis, trichomoniasis, gonorrhea and chlamydia. It is also important to perform urine tests with urine culture and sensitivity to exclude any urinary tract infection. If vulvar lesions are found, it is important to perform biopsy to exclude inflammatory causes such as lichen sclerosis or cancer such as squamous cell carcinoma.
Plan: How will you manage this patient? What interventions would you suggest?Cognitive behavior therapy- to help cope and manage pain.Sex therapy–help build techniques to reduce pain anxiety, ability to help the patient to communicate better, and find ways to help reconnect with their partner through nonsexual contact or emotional contact. Physical therapy- to help strengthen the pelvic floor and release tension in muscles and joints.Are there any treatments or medication would you prescribe and why?Topical lidocaine ointment- Lidocaine 5%, apply a thin film to skin as needed for pain. Do not use more than 20g of ointment in a 24 h period. Dispense 30g-tube. Refill: 0Explain treatment/management guidelines including any possible side effects and/or consideration management of the diagnosis. Lidocaine ointment possible side effectsItchingRashswelling According to Spadt et al. (2024), 5% lidocaine ointment only applied to the affected area for symptom control after sex play, it is low cost and readily available.
What patient education is important to include for this patient?
(Consider including pharmacological, supplements, and non pharmacological recommendations and education)Wear 100% cotton underwearDo not perform any douchingAvoid irritants such as shampoo, dyes or detergentsClean the vulva with water onlyRinse and pat to dry after urinatingAfter bathing may use a preservative free oil or petroleum jelly to hold in moisture and protect skin May use lubricant during sex, avoid lubricants with flavor or cooling/warming sensation. What is the follow-up plan of care?Follow up in 2 weeks.
2. Case Scenario 2
Table 1
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Sexuality |
Sexuality encompasses a wide range of traits, actions, and yearnings associated with attraction, expression, and intimate connections. |
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Sexual health denotes a condition of physical, emotional, mental, and social equilibrium concerning sexuality. |
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Sexual identity pertains to an individual’s internal understanding of their sexuality, encompassing factors such as sexual orientation, gender identity, and how they view themselves in relation to others regarding attraction, desire, and romantic or sexual connections. |
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Sexual orientation describes an individual’s consistent inclination towards emotional, romantic, and sexual attraction to others. |
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Sexual agency denotes an individual’s ability to independently and knowledgeably choose their own sexual behaviors, preferences, and connections. |
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The gender based on chromosomes, and anatomy that define a male or female. |
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The identity that the patient claims whether that be male or female |
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Transgender refers to individuals whose gender identity diverges from the sex they were assigned at birth, encompassing a spectrum of gender identities beyond the binary categorization of male and female. |
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Gender dysphoria is a psychological state marked by distress or discomfort felt by individuals whose gender identity does not align with the sex they were assigned at birth. |
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Cisgender is a term used to describe individuals whose gender identity aligns with the sex they were assigned at birth |
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A person who was assigned female at birth but identifies as a man from now on. |
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A person who was assigned male at birth but identifies as a woman from now on. |
(Garcia & Lopez, 2022)
Table 2
| Imbalance of hormonesNeuro disorders/dysfunctionsVaginal AtrophyChronic/acute illnessMedication side effects, or effects. |
| SSRIsAntipsychoticsHormonal contraceptivesAnti-hypertensivesFinasteride |
| StressAnxietyBody image concernsDepressionNot satisfied with relationship/partner |
| Hormone TherapyErectile dysfunction medication (Viagra)Therapy/couples therapyLifestyle modifications |
Table 3
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Define Vulvodynia: Vulvodynia is a long-lasting pain condition marked by continuous and unexplained discomfort in the vulva, the external female genital area. |
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Define Vaginismus Vaginismus is a condition marked by involuntary contractions of the pelvic floor muscles around the vagina, causing pain or difficulty with penetration during sexual activity. |
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What is the difference between the 2 diagnoses? Vulvodynia targets the vulva directly, while vaginismus entails involuntary muscle spasms surrounding the vagina, hindering penetration. |
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What are treatment options? Topical treatments, medications, nerve blocks for vulvodynia and for vaginismus: pelvic floor therapy, medication, education, gradual desensitization. |
Case Study: Ty is a 22-year-old who comes to your office for an annual physical exam. On the intake paperwork, you note the gender box is 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.
- Open-ended questions regarding sexual orientation and sexual preferences allow the NP to address specific risk factors as well as incorporate what is known about population level health disparities to improve the health of this vulnerable population (Alexander 2017).
How will you verify the patient’s name and preferred name?
Good Morning Ty, what would you like me to refer to you as?
How will you ask for the patient’s gender
Ty, at birth were you given the identity of a male or female? What do you identify as currently?
How will you ask for the patient’s preferred pronouns?
Ty, what are your preferred pronouns that you would like me to use?
SOAP Note
Demographic Data: 22-year old They/Them
Subjective
- Chief Complaint (CC): “I am here for my annual physical examination”
History of Present Illness (HPI): 22 y/o they/them presents to the clinic this morning for annual physical examination.
Onset: Have there been any changes in health since the last physical exam. Have you had any new symptoms or changes in existing symptoms since the last visit?
Location:If you are having any symptoms, where are they occurring? Including areas of pain, discomfort, or any other sensations in the human body.
Duration: How long have you had these symptoms? I will then be able to tell if these symptoms are acute or chronic.
Characteristic symptoms: What is the nature of the symptoms? Are they sharp, throbbing, intermittent, constant?
Aggravating or alleviating factors: Does anything make those symptoms better/worse? How about different activities, positions, medications, or other factors that affect the symptoms?
Related symptoms: Are there any other symptoms occurring alongside the main symptoms you mentioned?
Treatment or timing: Have you tried any treatments for these symptoms? If so, have they been effective? When do these symptoms typically occur and how often?
- Past Med. Hx (PMH):
Do you have any previous medical hx?
Have you been diagnosed with any other medical conditions?
Have you ever been hospitalized?
Do you have any other medical concerns or questions that you would like to address during this visit?
Do you have any chronic health conditions, and are they related to your gender identity or transition process in any way?
Are you currently taking any medications for chronic health conditions?
- Gyn/OB history:
Have you undergone any gender-affirming medical treatments or procedures, such as hormone therapy or surgeries? If yes, what type of treatments or surgeries have you had, and when did you undergo them?
- Past Surgical Hx
Have you had any surgeries in the past?
Have you undergone any gender-affirming surgeries?If yes, what surgeries have you had, and when did you have them?
Have you experienced any complications or issues related to these surgeries?
- Family Hx
What other family history should you ask?
Do you have a family history of chronic medical conditions?
Any history of any cancers in your family?
- Mother
- Father
- Siblings
- Grandmother
- Grandfather
- Current Medications
Are you currently taking any medications or OTC supplements?
Are you taking your medications as instructed/prescribed?
Are you currently taking any medications, including hormonal therapies or supplements?
- Allergies
Do you have any allergies?
- Immunizations History
Are you up to date on your immunizations?
Have you had the gardasil/HPV vaccine?
Covid vaccine?
Yearly flu vaccine?
Hep B?
Varicella?
MMR?
Meningococcal?
Tdap?
- Health Maintenance
Have you discussed preventive care recommendations specific to your gender identity and medical history, such as breast or chest health screenings, cervical cancer screenings, or prostate health screenings?- I was born a man, but I am now a female: based on the patient’s answer we would be testing the following.
-When was your last annual physical?
-When was your last eye exam ?
-When was your last dental visit ?
-Have you ever had a mental health examination?
- Social History
How many intimate partners have you had?
Do you engage in oral, vaginal, or anal contact?
Do you have sex with males, females, or both? Both
Do you engage in alcohol or drug use?
Do you smoke tobacco or use tobacco products? If so, how long? How many packs a day?
What is your current living situation?
Do you feel safe where you live?- very important question to ask.
What do you do for work?
Any anxiety/depression?
How is your support system?
What other social questions should you ask?
Are there any specific health concerns or risks associated with your gender identity or community that you would like to discuss?
Are you physically active, and if so, how often do you engage in exercise?
Have you ever experienced gender dysphoria or mental health concerns related to your gender identity?
Have you received any counseling or mental health support related to your gender identity or transition process?
What does your diet look like?
What is your caffeine intake?
- Review of Systems (ROS)
- General: Do you have any malaise, fatigue and weakness? Any weight loss, fever & chills? Have you had any change of health since your last visit?
- Endocrine: Any history of diabetes or thyroid disorders?
- Lymphatic: Any swelling in your lymph nodes?
- Cardiovascular: Have you noticed any chest pain and discomfort? Any palpitation, edema, swelling of extremities or changes? Any history of heart attack or heart failure?
- Respiratory: Any cough, shortness of breath, swelling? Any phlegm production?
- Skin & Breasts: Have you noticed any rashes, itching, or abnormalities on your skin? Any recent injuries? Discharge in the breast tissue? Any breast pain, or other abnormalities?
- Musculoskeletal: Any weakness or pain in your joints?
- Neuro: Have you had any recent headache, dizziness, or numbness/tingling in extremities?
- Immunologic: Any hx of HIV, TB, hepatitis, shingles, or recurrent infectious diseases? Any hx of cancer- radiation or chemotherapy?
- Genitourinary/GYN: Pt complains of burning on urination. Any hx of bladder/kidney stones/infections? Any abnormal or change in discharge?Any sexual dysfunction or concerns? At what age did you become sexually active? Do you have any pain with intercourse? Have you ever been diagnosed or had symptoms of an STI? Have you ever been tested for STIs? Do you use condoms?
Objective
Write a detailed focused assessment on this patient
- Therefore NPs must use the existing health-promotion guidelines established for all adolescents and adults and tailor them to individual patients, with a clear understanding of individual risk-taking behaviors, such as smoking or unsafe sexual behaviors, along with an understanding of population-level health inequities (Alexander, 2017). Breast exam in both supine and standing positions including the axillary and supraclavicular and infraclavicular spaces looking for mass, asymmetry, skin changes, and/or bloody nipple discharge and Redness, inflammation (rule out inflammatory breast cancer). Palpation of the breast away from the chest wall with the patient sitting or in a side lying position can help to differentiate parenchymal pain versus a chest wall etiology. Palpation of the ribs and musculature posterior to the breast mound can reproduce the pain. (Alexander, 2017).
- Vital signs:
Take in clinic
- General: Vital signs are stable, in no acute distress. Alert, well developed and well nourished.
- Neuro: Mood and affect intact.
- Cardiovascular: S1, S2 has regular rate/rhythm.
- Respiratory/ chest: unlabored breathing, equal chest rise and fall with equal bilateral breath sounds.
- Integumentary: No rashes or abnormal moles noted on visualized skin.
- Lymphatic: lymph nodes not palpable or tender.
- Breasts: Skin intact without lesions/rashes. No nipple discharge, no dimpling, retractions or peau d;orange appearance.
Assessment (Diagnosis/ICD10 code)
7 +8. What is your diagnosis + differential diagnosis?
Differential DX:
- Encounter for screening for infections with a predominantly sexual mode of transmission Z11.3
The likelihood of contracting HIV and STIs is determined not by a patient’s self-identified sexual orientation (such as being lesbian or gay) but rather by individual behaviors. Research also indicates a disproportionately high rate of HIV infections among transgender women—individuals who were assigned male at birth but now identify as women (Alexander, 2017).
(+) Pain or burning sensation during urination
(-) Discharge from the urethra or vagina
(-) Genital/anal itching, irritation, or soreness
(-) Genital/anal ulcers, blisters, or lesions
Working DX:
- Encounter for general adult medical examination without abnormal findings Z00.00
Prominent health organizations and advocacy groups within the LGBT community, such as the Institute of Medicine (IOM) and the Fenway Institute, advocate for healthcare providers (HCPs) to incorporate inquiries about sexual orientation and gender identity into routine patient assessments. Gathering this data from all patients enables HCPs to personalize both immediate and ongoing medical treatment based on individual risks and requirements. Additionally, it facilitates discussions about any past negative experiences with healthcare providers that might impact the patient’s access to and utilization of medical services (Alexander, 2017).
TX Plan (POCT):
Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.
1.Clinical Breast Examination
- Patient identifies as a female, and a breast exam was done on the patient. No abnormal findings on examination
2. Urinalysis
- Patient complaining of painful urination. To rule out a UTI, a test was done in the clinic. Negative for leukocytes, nitrates, blood in urine.
3. HIV/Syphilis/Gonorrhea and Chlamydia swab in clinic
- Pt is sexually active with multiple women and men and presents with symptoms of painful urination with a negative UTI. Patient will
Treatment plan
What are your next steps and plan of care for this patient? Explain rationale
- Call patient with results of STI/STD screening- if positive will be treated here in the office.
- Education for patient
- Pt. Education for DX:
What patient education is important to include for this patient?
Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s), partner notification, and follow-up plan of care.
- Quit smoking smoking and education on unsafe sexual behaviors
- Use barrier methods during sexual contact
- Use referral to mental health services
- Eat well rounded diet, use MYPLATE online to decrease risk of obesity
- Continue to go to all scheduled appointments for health maintance
Complications if patient does not comply with treatment regimen
Patients can be at increased risk of delayed diagnosis, decreased treatment outcomes in cases of malignancy, and reduced chances of survival (Alexander, 2017).
- Referral/Follow-up:
F/U in clinic within a week after receiving the results of STI/STD results. Will call with results- and will treat accordingly.
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