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Nurse Practitioner Case Example One

Section 1: Patient Case Overview

Provide a brief overview (1-2 sentences) of your patient, and reason for the NP-patient
interaction. Include any relevant past medical history and medication.

24-year-old female with a history of post-coital spotting and pelvic cramping x 2 months
- phone visit - done during covid pandemic - clinic model - not the primary care provider
of patient
PMH: none
Medication: none

Section 2: Health Assessment

NPs integrate an evidence-informed knowledge base with advanced assessment skills to
obtain the information necessary for identifying client diagnoses, strengths, and needs.

Based on the patient presentation, describe the health assessment you completed.

Detailed phone history: PMH, PSxH, Menstrual history - regular, any previous spotting,
etc., Medication history, sexual history, STI hx, allergies, symptom history - including
systemic symptoms, HPI of symptoms - amount of bleeding, frequency, associated symp-
toms, contraception history, previous PAP testing done
What are some specific questions you asked the patient? Provide a rationale for each
question you asked.
1. Do you have any medical/surgical history - to determine any potential contributing fac-
tors
2. Do you have any allergies - in case need to treat with medication
3. What is your menstrual history - how old were you at menarche? Do you have regular
periods? How long do they last? Are they heavy and/or painful? to determine any previ-
ous irregular spotting/issues or similar issues in past - sometimes can be difficult to dif-
ferentiate from postcoital, or dysmenorrhea
4. Medication hx/contraception - What are you using for contraception? Have you used
plan B or emergency contraception recently/currently? In the past? Any previous use of
contraception in the past - including an IUD? contraceptive hormone can cause irregular
spotting - especially if recent start (within 3 months or IUD in for few years) (although
limited to post coital is less likely), also potential of pregnancy, IUD can cause symptoms
- even non hormonal, if no contraception could be possible spotting in pregnancy or
threatened abortion
5. Sexual history - Are you currently sexually active, when was the last time you were
sexually active and last time without a condom (and last menstrual period - if no contra-
ception is possibility of pregnancy, also if unprotected is risk of STI)? How many part-
ners have you had in the past 2 months and past 12 months? Routes for sexually activity
(anal, vaginal, oral)? Any trauma/hard sex? (Consider trauma) Any history of an STI?
Have you been tested in the past - if so when was the last time? could be an STI - number
of partners and unprotected intercourse increase the risk, if currently sexually active and a
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positive STI could be infecting partner, trichomonas and/or chlamydia may cause post-
coital spotting; increased risk for STI if previously had an STI
6. Have you ever had a PAP test and if so an history of abnormal PAP- cervical cancer
may cause spotting
7. How heavy is the bleeding, do you need a pad, how long does it last for? Any fe-
vers/nausea/vomiting. Tell me about the pelvic pain - how bad is it - where is it how long
does it last for, when does it start - after sex - how long after, do your symptoms happen
every time - or is it intermittent, how long has this been going on for? When was the last
time you experienced it? Is it getting any better or worse? - may need to be evaluated for
anemia, if fevers or progressive pain/bleeding- could be PID, or evolution of symptoms -
may need ER
8. Do you have any other symptoms such as rashes/lesions in vulvar area, change in dis-
charge, dysuria, dyspareunia, etc. - to determine either contributing factors that may
cause spotting - such as STI, yeast, BV, UTI etc. - although some are less likely

Section 3: Diagnosis
NPs are engaged in the diagnostic process and develop differential diagnoses through
identification, analysis, and interpretation of findings from a variety of sources.

Discuss the investigations you ordered/performed, along with your findings.

Vaginal swab: Bacterial vaginosis, candidiasis; Urine NAAT: gonorrhea, chlamydia,

trichomonas; self-home urine pregnancy test
Why did you choose these specific investigations?
Rule out underlying STI that can cause post coital spotting - particularly chlamydia
and/or trichomonas. Less likely other testing however important to rule out if other test-
ing is negative
What features of the patient’s presentation led you to your top two (or three) differential
diagnoses?
Top DD: STI - post coital spotting - patient is having unprotected intercourse - thus at
risk - certain STIs can cause friability of cervix and postcoital spotting, and /or pelvic
pain - inflammation, PID
Pregnancy - less likely as had a menses regularly and symptoms ongoing x 2 months -
however having UPI thus is possible - was not on any contraception - including non-hor-
monal i.e., copper idd, had not used emergency contraception
Structural abnormality - endometrial lining, polyp, cervical, vulvar tissue

Were there other tests that you thought of but decided against? Why?

The above was the first testing and the results came back negative for all testing, thus
next diagnostics ordered were:
1. urine for urea mycoplasma: less likely to be cause although possible, choosing wisely
- this is not recommended as first line testing as can be positive and asymptomatic -
may remain positive after treating - starting a vicious circle which may not be under-
lying issue, however, is indicated if symptoms and can be secondary to an STI
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2. pelvic/transvaginal ultrasound: determine and structural abnormality - polyp, inflam-

mation as result of bleeding (underlying cause), thick or irregular endometrium, can-
cers/mass, etc.

Section 4: Therapeutic Management

NPs, on the basis of assessment and diagnosis, formulate the most appropriate plan of
care for the client and implement evidence-informed therapeutic interventions in partner-
ship with the client to optimize health.

Describe the plan of care you developed in partnership with the patient.

Phone visit - no in-person appointments available for ~ 4 weeks

1. advised if symptoms progress - i.e., heavy bleeding increased pelvic pain, etc., or de-
velops systemic symptoms - fevers nausea vomiting, feeling unwell, etc. = ER or a clinic
where can be seen in-person same day
2. abstain from sexual activity until symptoms resolved and testing back - could be STI -
spreading transmission, also is aggravating underlying cause
3. self swabs BV yeast, urine: rich, chlamydia gonorrhea - drop off at clinic - reviewing
sampling procedure - could not bring to clinic for in-cline visit as no appointments x 4
weeks - alternatively could go to another clinic where can be evaluated in-person; urine
home pregnancy
4. patient to call in 1 week for results of all testing; HCP (myself) watched for results:
plan - if normal - needed further reassessment - if persisting symptoms additional testing
5. follow up: see above other tests - I reviewed all testing and it was normal, thus I con-
tacted the patient and discussed results and current symptoms - same - no change - ar-
ranged for US and Urine urea-mycoplasma and lab urine pregnancy test - ordered) if pos-
itive then treat /manage accordingly; reinforced sexual abstain and if sexual activity con-
doms for contraception and STI protection; Also booked for in-person visit - next availa-
ble which was about 3 weeks - discussed option can seek other provider
Plan - needs exam - in-person - to see if any visible cause for bleeding (pelvic and abdo-
men exam); if ultrasound and urine pregnancy and mycoplasma negative will refer to gy-
necology for dysfunctional uterine bleeding; no PAP done as guidelines = start at 25 yo -
gyne may do sooner.

What features led you to choose the treatment that you did?

Stable, postcoital bleeding - light spotting, unprotected intercourse, mild pelvic pain, no
progression in symptoms, history - STI hx neg, contraception nil, reg menses, etc., age

What were the patient’s expectations for treatment?

Eventual resolution of symptoms - follow up until determine underlying cause and ad-
dress
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What sources of evidence informed your treatment plan?

Toronto public health guidelines for STI, UpToDate: postcoital bleeding in premenopau-
sal females: PAP guidelines - Canada Task Force and Ontario Cancer screening

What did you decide was appropriate for follow up?

Follow up 1 week post testing (ER if progression) - see details as described above.

Section 5: Collaboration, Consultation, Referral

NPs identify when collaboration, consultation and referral are necessary for safe, com-
petent, and comprehensive client care.

How did you decide whether or not to collaborate, consult or refer to a health care team
member?

Determined when beyond scope - patient will need colposcopy and biopsy by gyne if
testing all normal or if indication with US results - pending
Once exhausted all reasonable work up and still unable to determine underlying cause
will need gynaecology specialist

What was the outcome of the collaboration/consultation/referral (if applicable)?

Not applicable yet - awaiting US results and urine testing

Final thoughts

Looking back on this patient case, is there anything that you would have done differ-
ently?

No - it is unfortunate with covid that in-person visits are restricted and as such our clinic
does have significant wait however, I do keep on top of things virtually and connect with
the patients regularly to avoid extended delays that may impact outcome; also discuss op-
tion of seeking care elsewhere at walk-ini clinic where can be seen same day; also discuss
ER if progression. Overall, I think that this patient is getting good care - there is close
monitoring, regular follow up (phone) and an ongoing plan in place as described

Is there anything that you would like to add about this case example, that hasn’t been
covered?

No