hot flashes, and cramping,
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CaseSample_ASTUDENTSAMPLE.docx
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)
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
