CC: I have this vaginal bleeding during intercourse x 2 weeks.

37 y/o F G7P2 w/no PMHx, presents to the ED complaining of vaginal bleed during intercourse x 2 weeks. Pt states that for the past 2 years she has been experiencing consistent brownish vaginal discharge, but for the past 2 weeks she noticed some postcoital bleeding. She explains the bleeding occurs only after intercourse and denies any dyspareunia, however the vaginal discharge occurs on all days other than when she has her period. She does not have a GYN provider, so she came to the ED today to be evaluated. Her last PAP test was 8 years ago and was normal and she has not seen a GYN doctor since then. She gets her period around the same time each month and the duration and the flow of the period are the same each month (4-5 days uses 2-4 pads each day). Her last menstrual period was on 7/8/19 and her usual menstrual cycle is every 24 days. She is currently sexually active with only one partner (her husband) and is using condoms for protection. She denies any vaginal pain, dryness, itching, or pressure. She also denies any fevers, chills, N/V/D, hx of STDs, recent weight loss or gain, night sweats, chest pain, SOB, palpitations, constipation, dysuria, urinary frequency or urgency, flank pain, vaginal odor,  bleeding or spotting between periods.

DDX:

Cervical cancer- The most serious cause of postcoital bleeding

Cervicitis- is associated with purulent or mucopurulent discharge, but postcoital bleeding may also occur.

PID-

Endometriosis

Cervical polyps

Cervical ectropion

Fibroids

Past surgical hx

none

Medications

No known current medications

Allergies

No known drug or seasonal allergies

Family history

Denies family hx of breast, ovarian and endometrial cancer

Social History

• She is married and lives with her husband and her 2 kids, which she delivered vaginally without complications.
• She works in an office.
• Denies hx of smoking cigarettes, illicit drug use or alcohol consumption.
• She is currently sexually active with her husband and uses condoms. Denies hx of STIs.
• She does not follow any specific diet and admits that she frequently eats fast food.

O

Vitals

BP :119/78 (right arm, sitting) HR: 67 bpm, regular, RR:16 bpm, unlabored, Temp: 98.6F (oral), SpO2: 99% (room air) BMI: 32.7

General:

Skin – skin color, texture, turgor normal, no rashes or lesions

Lungs – clear to auscultation bilaterally, respirations unlabored, no adventitious sounds

Chest wall – no tenderness or deformity, no paradoxic respirations or use of accessory muscles noted

Heart – regular rate and rhythm, S1 and S2 normal, no murmur, rub or gallop

Breast exam – no tenderness, masses, or nipple abnormality bilaterally

Abdomen – flat, symmetrical, soft, non-tender, bowel sounds active in all four quadrants, no masses, no organomegaly, no CVA tenderness

Pelvic exam – no erythema, inflammation, ulcerations, lesions or discharge noted; vaginal mucosa without inflammation, erythema or discharge; cervix multiparous with a small polyp noted. No discharge; no cervical motion tenderness; uterus is non-tender, and of normal size, shape, and consistency; adnexa without masses or tenderness

Rectal exam – patient refused

Extremities – skin normal in color and warm to touch upper and lower extremities bilaterally; no calf tenderness bilaterally, equal in circumference; no cyanosis/clubbing/edema noted bilaterally

Labs

POC pregnancy, urine – negative

UA: WNL-no sign of infection

CBC: WNL

HCT: 38.2   HGB: 12.7 – WNL

Imaging:

Pelvic and transvaginal sonogram- shows soft tissue nodule on cervix, otherwise unremarkable.

Assessment:

37 y/o F with no PMHx presents to ED c/o, vaginal discharge x 2 months and postcoital bleed x 2 weeks. Pelvic exam showed small cervical lesion/mass. Ultrasound shows soft tissue nodule on cervix, otherwise unremarkable. Labs show no signs of anemia. Urinalysis shows no sign of infection. Possible polyp but must rule out malignancy.

DDX:

Cervical cancer- more serious

Cervical polyp- less serious

 

Plan:

Outpatient GYN referral and appt within the next week.

Patient information:

You underwent some tests today to help us understand why you are having theses symptoms. The tests show that you may have some type of cervical lesion. You need to follow up with a GYN doctor for further evaluation of your symptoms. The GYN specialist can perform testing in order to determine the nature of the lesion. Please be sure to keep all appts and return to the ED if you have any other concerning symptoms.