History

Full Name: K.G. 

Age: 42 years

Date & Time: July 1, 2024

Location: Woodhull Medical Center

Source of Information: Self

Reliability: Reliable

Source of referral: Self

Mode of transportation: Walk-in

CC:

“Sometimes I feel a bulge in my vagina” x1 month.

HPI:

K.G. is a G5P4014 female, LMP 06/23/2024, who presents to the outpatient clinic today with complaints of a feeling a bulge in her vagina. Pt mentions that this began suddenly about one month ago and occurs sporadically. She denies being able to cause the bulge to descend via coughing or valsalva maneuver and says she only feels it randomly. It lasts between a few seconds and a few minutes and then the sensation passes. She admits to seeing this bulge at the introitus with prolonged standing. She also mentions that she has not yet tried anything to help with improving this issue. She denies any pain in the area, but does admit to feeling a pressure like sensation. Pt admits that sometimes when she sneezes or coughs, she leaks a small amount of urine. Pt says this is bothersome, but does not interrupt her daily living. 

Pt denies dysuria, urinary frequency, urinary urgency, chronic cough, heavy lifting, constipation, changes in bowel habits, recent surgeries, trauma to the area, recent/recurrent infections, change in sexual habits, pain with tampon use and hematuria. 

Medical History:

• Seasonal allergies

Medications:

• Cetirizine 10 mg once daily PRN allergies

Surgical History:

• No past surgical history.

Allergies:

• No known drug/food/environmental allergies

Ob/gyn History:

• NSVD x4
• Last pap 4/2/24- neg
• Denies history of STDs

Family History:

• Mother: Unknown
• Father: Unknown
• 4 children: alive and well
• No known family history of cancer or cardiac disease

Social History:

• Smoking: Denies
• Alcohol: Denies
• Illicit drug use: Denies past or current use
• Marital History: Married
• Language: English
• Occupational History: Unknown
• Travel: No recent travel
• Home situation: Lives at home with family
• Sleep: Endorses adequate sleep
• Exercise: Walks around the block daily
• Diet: Reports diet heavy in carbs, vegetables and protein. Eats a lot of junk food.  
• Caffeine: Denies caffeine use 

ROS:

• General: Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies epistaxis, nasal congestion, sore throat, head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, discharge, bleeding gums.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Breast: Denies lumps, nipple discharge, or pain.
• Pulmonary: Denies cough, hemoptysis, dyspnea, wheezing, cyanosis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary: Admits to incontinence. Denies urinary frequency, nocturia, urgency, flank pain, oliguria, polyuria, vaginal discharge, dysuria and malodorous urine.
• Menstrual/Obstetrical: G5P4014, LMP 06/23/2024; sexually active with her husband 
• Musculoskeletal: Denies back pain, muscle pain, joint pain, arthritis and joint swelling.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric: Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional.

Physical

General:

• Well developed, obese female in no apparent discomfort. Appears stated age of 42. Neatly groomed, alert and oriented x3.

Vital Signs: 

• BP: 110/76 mm Hg
• R: 18/min, regular rate and rhythm, unlabored
• P: 93 beats per minute, regular rate, rhythm and amplitude 
• T: 98.5 degrees F (temporal)
• Height: 67 inches Weight: 233 lbs BMI: 36.49

Lungs:

• Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac Exam:

• Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal Exam:

• Abdomen with rounded contour, symmetric with no scars, striae or pulsations noted. Nontender to palpation and tympanic throughout, no guarding or rebound noted. 

Pelvic Exam:

• Vulva:Normal female external genitalia without erythema or lesions. 
• Vagina: Pink mucosa without inflammation, erythema or discharge. 
• Cervix: Multiparous, pink and without lesions or discharge. No cervical motion tenderness. 
• Uterus: Anterior, midline, smooth, non-tender and not enlarged. Stage 1 uterine prolapse, stage 1 cystocele. 
• Adnexa: No tenderness or masses noted. No inguinal adenopathy.

Differential diagnosis:

• Pelvic organ prolapse
  • Pelvic organ prolapse consists of cystoceles, uterine prolapse and rectoceles. The biggest risk factor for these things is vaginal deliveries, and the risk increases with increasing number of deliveries. This is relevant in this pt because she has had 4 vaginal deliveries. This pt presents with symptoms more indicative of a cystocele or uterine prolapse because she has urinary symptoms without any bowel symptoms. Both cystoceles and uterine prolapse can lead to a feeling of a bulge and pressure in the vagina. 
• Urethral diverticulum
  • A urethral diverticula is when an outpouching forms in the urethra and can fill with urine which lends itself to making a bulge sensation in the vagina. Additionally, urine will leak out. This usually occurs secondary to inflammation and infections. This makes the diagnosis less likely in this patient because she denies recurrent infections.
• Bartholin gland cyst
  • A Bartholin gland cyst is a fluid filled sac that forms by the vaginal opening or in the vaginal wall. This may cause a bulge like sensation, but will also cause more pain than what the pt described as “pressure.” This diagnosis also does not explain the incontinence that the pt is experiencing. She also denied pain with tampon use, which is common with this diagnosis. 

Assessment:

• 42 year old obese female G5P4014 with complaints of feeling a vaginal bulge for one month. She has associated stress incontinence as well. On exam, a stage 1 cystocele and uterine prolapse was palpated with the remaining exam being within normal limits. There is no imaging or labs to review at this time. Her presentation is most likely due to pelvic organ prolapse.

Diagnosis:

• Pelvic organ prolapse

Plan:

• Pelvic organ prolapse
  • Conservative (pessary, kegel exercises) vs. surgical options discussed. Pt expressed desire to pursue surgical treatment.
  • Referral to uro-gyn
  •  Educate regarding benefit of weight loss and limiting heavy weight lifting
  • Return to clinic in 4-6 weeks to discuss further plan based on uro-gyn recommendation