The comprehensive assessment and prevention of women’s diseases are mandatory medical practices maintained in most healthcare facilities. Such illnesses are complicated by the fact that their consequences may be extremely dangerous, and other systems of the body, as a rule, are also threatened. Infertility is one of the risks that can occur if particular attention is not paid to a certain disease in time. Based on the analysis of the woman’s visit to a medical specialist, it is possible to consider how clinical testing of the body condition occurs, what symptoms manifest, and what treatment plan may be required.
The object of Outpatient Checkup and Primary Analysis
A 32-year-old woman applies for an appointment with a gynecologist in a public clinic. The main complaints are redness in the vaginal area and occasional bleeding. The patient denies any type of pain but argues that she is concerned about too frequent excreta that does not depend on her menstrual cycle. Despite the absence of obvious symptoms, the woman confirms that she experiences discomfort after sex acts, in particular, itching. She also denies taking any hormonal drugs and mechanical damage to her problem area. According to her, the last time, she was on a gynecological examination about six months ago, and no pathologies were found. Based on the results of the initial examination, a deeper assessment is required for the key cause of the problem to be identified.
Subjective Data Analysis
Subjective data analysis will be the initial stage of the patient’s comprehensive assessment and subsequent intervention. Based on the information obtained during the survey, the overall picture will be compiled, and further evaluation will be based on the words of the woman. To obtain all the necessary information, the patient’s chief complaints will be heard, and the history of the present illness will be studied.
Chief Complaints
The patient’s chief complaints are related to suspected problems in the genital area. The woman does not confirm any type of pain; however, she argues that periodic bleeding scares her. Her menstrual cycle is not affected, but during the past few months, she has noted a shift in its schedule. According to the patient, slight redness is observed on the surface of the genitals, and slight itching is felt after sex acts.
History of Present Illness
For the first time, the woman noticed suspicious bleeding a few weeks ago. According to her, she thought that it was the beginning of her menstrual cycle. Although bleeding did not coincide with the menstruation schedule, the woman did not experience anxiety since she had had shifts before. However, in a few days, the situation repeated, and she felt nervous. Also, the patient remarks that two weeks ago, there was discomfort after a sex act, and slight redness appeared in the genital area. The woman notes that she was examined by a gynecologist about six months ago. Also, she denies casual unprotected sex and argues that she has a husband.
Review of Systems
Based on the conversation with the patient, she does not complain of discomfort in other systems of the body besides the urogenital. She has no problems with digestion and denies problems with sleep. The woman also notes that she does not experience any weakness that occurs during menstruation. When reviewing her appearance, there is no suspicion of hormonal disruptions, endocrine disorders, or the manifestations of autoimmune diseases.
Primary and Secondary Diagnoses
After conducting a physical assessment and making relevant tests, it is possible to talk about the problem. Based on the results obtained during clinical tests, the primary diagnosis is cervical ectopia. As Mitchell, King, Brillhart, and Goldstein (2017) note, the typical symptoms of this disease are “discharge, vulvovaginal discomfort, and dyspareunia” (p. e212). Also, according to the woman’s previous checks, no congenital abnormalities were detected. The instability of the menstrual cycle is often a frequent attendant problem. Although in this case, treatment will be simple, it is necessary to take appropriate measures immediately. According to the guideline presented by Parekh, Donohue, Men, Corbelli, and Jarlenski (2017), inaction can lead to cervical cancer, which is a significantly more serious problem.
The secondary diagnosis that is less likely is cervical erosion. In its classic version, infection occurs after any interventions that may damage vaginal tissues. Moreover, the physical examination did not reveal serious inflammation, which is typical for this disease. The woman denies having abortions or surgeries in the area of the uterus. Therefore, despite similar symptoms, the probability of erosion is significantly higher and is proved by tests.
Treatment Plan
According to the observations, the patient’s ectopia is not dangerous. According to Cotarcea et al. (2016), in this case, after conducting ultrasound monitoring, it is necessary to perform colposcopy and cytology tests. As diagnostic procedures, the vaginal area of the cervix may be stained with preparations containing iodine. Places with pathology remain not colored, and healthy zones become brown. In case of potential complications, laser vaporization can be applied, which, as Younus and Awazli (2018) note, is the effective method of preventing the spread of infection. Further observation is necessary to monitor the state of the disease and the progress of recovery.
Conclusion
Based on examinations and clinical testing, the patient has acquired cervical ectropia. The tests performed to confirm that the disease does not have a dangerous form. Cervical erosion may be considered a secondary diagnosis due to similar symptoms. As a treatment plan, colposcopy and cytology tests should be performed. Also, the diagnosis may consist of staining the healthy area of the vagina with iodine to isolate the zone of infection. Ultrasound monitoring is an important procedure for determining the severity of the disease and eliminating more dangerous problems, for instance, cervical cancer.
References
Cotarcea, S., Stefanescu, C., Adam, G., Voicu, C., Cara, M., Comanescu, A.,… Pană, R. (2016). The importance of ultrasound monitoring of the normal and lesional cervical ectropion treatment. Current Health Sciences Journal, 42(2), 188-196. Web.
Mitchell, L., King, M., Brillhart, H., & Goldstein, A. (2017). Cervical ectropion may be a cause of desquamative inflammatory vaginitis. Sexual Medicine, 5(3), e212-e214. Web.
Parekh, N., Donohue, J. M., Men, A., Corbelli, J., & Jarlenski, M. (2017). Cervical cancer screening guideline adherence before and after guideline changes in Pennsylvania Medicaid. Obstetrics & Gynecology, 129(1), 66-75. Web.
Younus, H. M., & Awazli, L. G. (2018). CO2 laser treatment of cervical ectropion. Iraqi Journal of Laser, 15(B), 35-39.