OB H&P2

CHIEF COMPLAINT:

  • “Severe pain in my vagina.”

HISTORY OF PRESENT ILLNESS:

  • 34-year-old G1P1 woman presenting to the emergency room with severe pain in the vaginal area for the past 4 days, which has become increasingly severe in the last 2 days. She describes the pain as sharp and throbbing, localized to the left side of the vulva. She rates the pain as 8/10. She reports that initially, the pain was mild and manageable but has progressively worsened, making it difficult to sit or walk. She denies any trauma to the area. She states she was sexually active 5 days ago with her husband and reports symptoms have started since then. Denies any recent history of STDs and reports only being sexually active with her husband.She denies fever, chills, urinary symptoms, or abnormal vaginal discharge. 

MEDICAL HISTORY:

  • Medications:
    • None
  • Medical History:
    • No significant past medical history
    • History of Chlamydia infection in her late teens, treated successfully
  • Surgical History:
    • Cesarean section 7 years ago
    • Bartholin’s cyst a year ago, treated successfully
  • Allergies:
    • No known drug allergies
    • No known food allergies
    • No known environmental allergies

FAMILY HISTORY:

  • Mother: Alive & well, hx of hypertension
  • Father: Alive & well, hx of hyperlipidemia

SOCIAL HISTORY:

  • Smoking: Nonsmoker
  • Alcohol: Occasional social drinker
  • Illicit Drug Use: Denies
  • Occupation: Office manager
  • Caffeine: Reports moderate use (1-2 cups of coffee daily)
  • Marital Status: Married
  • Home Situation: Lives with husband and 7-year-old son
  • Diet: Reports a balanced diet
  • Exercise: Exercises regularly, including jogging and yoga

GYN HISTORY:

  • Last PAP smear 12/23, results normal
  • Menstrual cycles regular, 28-30 day cycle
  • Sexually active with her male partner for the past 10 years, does not use protection
  • No recent history of sexually transmitted infections
  • History of Chlamydia infection in her late teens, treated successfully

REVIEW OF SYSTEMS:

  • General: Denies recent weight loss or gain, fever, or fatigue.
  • Skin: Denies rashes or lesions.
  • Breast: Denies lumps, tenderness, or discharge.
  • Cardiac: Denies chest pain, palpitations, or syncope.
  • Pulmonary: Denies cough, wheezing, or shortness of breath.
  • Gastrointestinal: Denies nausea, vomiting, diarrhea, or constipation.
  • Genitourinary: Reports severe pain and swelling in the left vulvar area. Denies dysuria, hematuria, or increased urinary frequency.
  • Musculoskeletal: Denies joint pain or muscle weakness.

PHYSICAL EXAM:

  • General: Well-nourished, well-developed 34-year-old female in no acute distress but appears uncomfortable due to pain.
  • Vitals:
    • BP: 128/78 mmHg
    • Pulse: 84 bpm
    • Temp: 98.6°F
    • Wt: 145 lbs
    • Ht: 5’5”
    • BMI: 23.7 kg/m²
  • Skin: No rashes or lesions.
  • Breast: Symmetric, no masses, no axillary lymphadenopathy.
  • Cardiac: Regular rate and rhythm, no murmurs, gallops, or rubs.
  • Lungs: Clear to auscultation bilaterally, no wheezes or crackles.
  • Abdomen: Soft, non-tender, no masses or organomegaly.
  • Genitourinary: Left labia majora is swollen, erythematous, and tender to palpation. A fluctuant mass approximately 3 cm in diameter is noted in the 7 o’clock position on the left vulvar region, consistent with a Bartholin’s cyst. No signs of abscess formation or purulent discharge. Right labia majora is normal. No cervical motion tenderness. Uterus is non-tender and of normal size. No adnexal masses or tenderness.

DDx

Bartholin Cyst

Bartholin Gland Abscess  

HSV infection

ASSESSMENT:

  • 34-year-old G1P1 female presenting with severe left vulvar pain and swelling, consistent with a Bartholin’s cyst.

PLAN:

  • Bartholin’s Cyst:
    • Incision and drainage of the cyst to relieve pain and swelling.
    • Culture and sensitivity of cyst fluid/NAAT for gonorrhea and chlamydia. 
    • Patient states she has tylenol at home, educated on taking as needed for pain relief.
    • Warm sitz baths 2-3 times daily for comfort and to promote drainage.
    • Follow-up appointment in 1 week to evaluate healing 

Education:

  • Educate patients on signs of infection to watch for, such as increased pain, fever, or purulent discharge.
  • Discuss the importance of follow-up care and potential need for further treatment if cysts recur.