Peer response to each case (2 cases) 300 words each roughly no cover page needed

Case 1- agree or disagree with the following peer posts 

Ty is 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.

Answer the following in complete sentences or in question format as if you are asking the patient these questions:

1. How will you verify the patient’s name and preferred name?

• “Hello Ty! How do you prefer to be addressed? Also, could you please share your legal name for identification purposes?”

1. How will you ask for the patient’s gender?

• “In order to ensure we address you appropriately, can you share your gender identity with us?”

1. How will you ask for the patient’s preferred pronouns?

• “What is your preferred pronoun you would like us to use when addressing you so that we can make sure we use the appropriate ones?”

CC: Pt p/w “physical exam”

HPI: 22 y/o F (at birth) now nonbinary, denies PMH p/w annual physical assessment.  Patient states was female at birth and now is nonbinary. Identifies as “they or them”. Patient states they are not on medications such a hormone therapy. Patient states would like to have mastectomy in the future however uses binder to flatten breast at this time. Patient states has not had new sexual partners in the last 30 days but does have intercourse with both males and females. Patient endorses does not use protection and is not on BC. Patient states has never had PAP smear before. Patient denies any hx of STI, vaginal, discharge, pain, odor, or irregular bleeding.

PAST MEDICAL HISTORY: denies

MEDICATIONS:  denies

FAMILY HISTORY:

• Mother: alive age 70, DM
• Father: alive age 71, DM
• Sibling: N/A.

ALLERGIES: denies

SOCIAL:

• Nutrition: balanced meal.
• Exercise: plays pickle ball
• Substance Use: denies.
• Sexual Hx: nonbinary, no new partners in the last 30 days but has intercourse with both genders. Denies hx of STI’s in the past. patient doe not use protection
• Occupation: college student
• Housing: lives in dorms

ROS (review of systems)

• General: Patient sleeps 8 hours /night. Denies any use of medication.
• Constitutional: denies weight loss, fever, chills
• Cardiovascular: Denies CP
• Breast: Denies tenderness, lumps, or bumps to breast
• Respiratory: Denies cough or SOB
• Gastrointestinal: Denies abdominal pain/discomfort fever, chills,
• GU: patient endorses increase incontinence. Denies urinary discomfort, blood stools, hematuria.
• Genitalia: patient denies vaginal pain, bleeding, odor, discharge
• Psychiatrics: Denies anxiety or depression

• Medical/Surgical/Psych History
  • Surgeries: denies

OBJECTIVE

• Vital Signs:
  • BP:115/69, Pulse: 78 Respirations: 16, Temperature: 98.4, Pulse ox: 100% RA Ht:160 cm Weight: 130 lbs BMI: 22.0
• Physical Findings:
  • General Survey: Pt is awake and alert, acting appropriately. Able to make needs known, dressed appropriately.
  • Cardio: peripheral bilateral radial pulses are present with regular rhythm. No murmur, gallop, clicks, or rubs with normal rate and rhythm. Normal S1 and S2, no S3 or S4 noted.
  • Pulmonary: Respirations even unlabored, chest appears symmetrical, lungs clear to upper and lower lobes on auscultation. Speech clear. (-) wheezes or crackles noted.
  • GI: abdomen is soft/nontender to touch. (+) bowel sounds heard to all quads (-) rebound tenderness. (-) CVA tenderness.
  • Breast Exam: bilateral breast symmetrical, No axillary lymph node enlargement noted, soft, nontender, no mass noted or felt, no dimpling, discharge, ulceration.
  • GU: deferred at this time.
  • Gyn: Vulvar Exam: no redness and irritation in and around labia fold nontender to touch on exam. no rashes/ prolapse Cervical Exam: is smooth pink, (-) motion tenderness, odor. No discharge noted. Uterus: midline, anteverted, non-tender in exam. Adnexae: No obvious masses or tenderness bilaterally, Bi-manual Exam: nontender to palpation upon exam.

ASSESMENT

• Working Diagnosis:
  • 9: Gender identity disorder, unspecified.:  Those who don’t think their gender can be put into one of two categories are called “non-binary.” They don’t just see themselves as men or women; they understand their gender in more ways than one. (National center of transgender equality, 2024)

PLAN

• DIAGNOSTIC STUDIES:
  • Labs:
    • PAP- WNL
      • Ty doesn’t have to get a pap smear unless they are showing signs of an illness or have had a history of abnormal pap smears in the past. However, because they are sexually active with both genders I would educated them that cervical cancer screening tests include pap smears.
    • U-Peg- Negative
    • UA: Negative
    • CBC: WNL
    • CMP: WNL
    • STI:
      • GCCT HIV/Trich/ syphilis
    • Sure swab: BV, yeast

• Pharmacological:
  • Pt chooses not take any medications at this time.
• Non-Pharmacological
  • The provider should make sure Ty has the right tools and help, like finding out about LGBTQ+ support groups, hospitals, or counselling services in the area, in case he needs them. To make sure a patient is healthy and happy all around, it is important to give them full sexual health information and care that is tailored to their needs and concerns.
• Referral:
  • LQBTQ+ support group
  • Counseling services

• Education:
  • What are some educational considerations should you include in regarding having a male partner?
    • Patient should be educated on should safe ways to have sex, like using condoms and water-based lubricants, to avoid getting STIs and lower the risk of getting HIV. It is also important to discuss the risk of STIs and how important it is to get tested regularly. I would also include discussing about HIV PrEP and PEP as an option based on the patient’s level of risk and sexual experience. Both PrEP and PEP are medicines that can help stop the spread of HIV if they are used regularly or after a possible contact (CDC, 2024).
  • What are some educational considerations should you include in regarding having a female partner?
    • It’s important to talk about safe ways to have sex, like using condoms and tooth dams to avoid getting STIs. Also, it’s important to talk about the risk of STIs, how important it is to get regular gynecological checks and cervical cancer screenings, and how to use birth control. Discuss to the patient evn though she does not identify as female, it is important to get routine checks like breast exams and discuss vaccines such as HPV You could also talk about the HPV vaccine and how important it is to get checked for breast cancer (CDC, 2024).

• Health Maintenance:
  • F/u for HPV vaccine

References

1. (2024). HIV Testing, Prevention and Care for Transgender People. Retrieved from https://www.cdc.gov/hiv/clinicians/transforming-health/health-care-providers/prevention-and-care-data.html

National guidelines of Transgender Equality (2024). Understanding Nonbinary People: How to Be Respectful and Supportive. Retrieved from https://transequality.org/issues/resources/understanding-nonbinary-people-how-to-be-respectful-and-supportive

Case 2: agree or disagree with the following peers post

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.

 

Demographic

25yo, female

CC: “I have not been able to use tampons, have a pap smear, or have sexual intercourse because I have so much pain with trying to insert anything into my vagina.”

HPI:  Patient in clinic today d/t vaginal pain hindering her from tampon use, pap smears, and vaginal intercourse.  Patient is unsure of when this issue began, she only noticed the pain at the age of 19 when she tried to use tampons for her period.  Patient reports that the pain is so severe that she cannot tolerate using tampons or having intercourse, which caused her boyfriend to break up with her.  Patient has never had vaginal intercourse.  Patient attempted to have pap smear in the past, but could not tolerate insertion of the speculum.  Patient with no hx of STI.  LMP 2/15/24.  Patient reports no hx of vaginal trauma.  Patient does not use any form of birth control at this time.

Medications

None

PMH

None

Surgical

None

Allergies

NKDA

GYN: G0P0, LMP 2/15/24, no hx of STI, no pap hx

Family

Mother- none

Father-none

Maternal grandmother- CVA

Paternal grandfather- DM

Social HX

Patient is 25yo female.  Patient lives in apartment with friends.  Patient works as an elementary school teacher.  Patient reports social alcohol consumption, no tobacco or illegal drug use.  Patient does CrossFit 3-4x weekly, and follows a vegetarian diet.

 

ROS

General: reports no malaise, no weakness, no chills, denies weight loss/gain of >20 lb over the past 6 months.

-Cardiovascular- Denies chest discomfort, heaviness, or tightness. Denies abnormal heartbeat or palpitations.

-Respiratory- denies SOB or cough

-Genitourinary: Denies dysuria, frequency, or urgency. No hx of UTI/kidney infection

-GYN: Reports extreme pain at her introitus, unable to insert anything into vaginal.  Denies vaginal discharge or odor.

Physical Exam

112/64, 65. 16. 97.9, 63in, 112lb, 19.8BMI

-Constitutional/General appearance- vital signs stable, patient alert and oriented.

-Head- atraumatic, normocephalic

-Respiratory- even and unlabored breathing, symmetrical chest expansion, bilateral clear lung sounds

-Cardiovascular- heart rate and rhythm normal, S1, S2 without murmurs, rubs or gallops appreciated.

-Breast- breast exam performed- no pain elicited with palpation of breasts, no masses, lesions, or discharge noted

-GI- abdomen soft, non-tender

-GYN-topical lidocaine applied to vaginal area, pap smear performed with smallest speculum- Normal external genitalia w/out lesions or erythema. Vaginal mucosa pink, and well supported. Cervix pink. No masses were palpated.  TVUS performed to r/o anatomical issues.

 

Assessment

DDX

Vulvodynia N94.81

Vulvodynia is pain in your vulva that lasts longer than three months. Unlike vulvar pain that results from a condition, vulvodynia doesn’t have a clear cause. The pain can be so life-altering that it keeps you from engaging in activities you enjoy. Treatment may include medicine, physical therapy, surgery and behavioral health support.

Working Dx

Vaginismus N94.2

Vaginismus is a condition characterized by involuntary muscle spasms in the pelvic floor muscles, specifically the muscles around the vagina. These spasms can make vaginal penetration painful, difficult, or impossible. Vaginismus can occur in women of all ages and may have a significant impact on quality of life.  The exact cause of vaginismus is not well understood, but it is believed to involve a combination of physical and psychological factors. Physical factors may include infections, trauma, or surgery, while psychological factors such as fear, anxiety, or past traumatic experiences may also play a role.

Plan

Referrals

Pelvic floor physical therapy: Pelvic floor physical therapy involves exercises and techniques to help relax and desensitize the pelvic floor muscles. This can help reduce muscle spasms and improve the ability to tolerate vaginal penetration.

Counseling: Counseling with a sex therapist or psychologist can help address underlying psychological factors, such as anxiety or fear, that may be contributing to vaginismus. Education about sexual anatomy, arousal, and techniques for comfortable vaginal penetration may also be beneficial.

Education

Gradual desensitization: A process of gradually increasing exposure to vaginal penetration can help desensitize the body and reduce fear and anxiety. This may involve using vaginal dilators of increasing size or engaging in other forms of sexual activity that do not involve penetration.

 

Medication: In some cases, medications such as muscle relaxants, low-dose antidepressants, or topical lidocaine may be prescribed to help relax the pelvic floor muscles and reduce pain.  These options will be discussed with patient.

Follow-up

Patient to RTC in 6 weeks to assess improvement of symptoms.

 

References

How do I know if I have vaginismus? (n.d.). Hope & Her. https://hopeandher.com/pages/vaginismus-diagnosisLinks to an external site.

Tayyeb M, Gupta V. Dyspareunia. [Updated 2023 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562159/