NU569 SOAP Note

NU569 SOAP Note

Student Name

Purdue University Global

NU569 FNP I Clinical – Lifespan Health Focus

Prof. Name:

Date

NU569 SOAP Note

Patients with an intrauterine device (IUD) who experience new vaginal discharge, spotting, and lower abdominal cramping should seek medical evaluation, particularly if they have not had menstrual bleeding for several years. While hormonal IUDs such as Kyleena can cause irregular bleeding patterns, symptoms including pelvic pain, abnormal discharge, and spotting may also indicate hormonal changes, cervical irritation, infection, pregnancy-related concerns, or other gynecologic conditions that require assessment.

Patient Presentation

A female patient presented with complaints of vaginal discharge, intermittent spotting, and lower abdominal cramping. The patient reported experiencing lower abdominal cramps for approximately three days and spotting once daily over the previous six days.

The patient has had a Kyleena intrauterine device (IUD) in place since 2019 and noted that she has not experienced menstrual periods since insertion. Prior to IUD placement, she used oral contraceptive pills for several years and is therefore unable to describe her typical menstrual cycle pattern.

She described the vaginal discharge as stringy with an appearance similar to old blood. At times, the discharge was accompanied by a milky or clear mucus consistency. Additionally, the patient reported intermittent lower back pain.

She denied the following symptoms:

• Fever

• Fatigue

• Chills

• Changes in appetite

• Nausea or vomiting

• Diarrhea or constipation

• Urinary frequency or urgency

• Hematuria (blood in urine)

• Pain during sexual intercourse

The patient reported her last sexual encounter occurred on Friday with the same sexual partner she has had since her sexually transmitted disease (STD) screening in 2019.

Medical History

Gynecologic History

• Last menstrual period (LMP): Unknown

• Hormonal contraception: Oral contraceptive pills prior to 2019

• Current contraception: Kyleena IUD (inserted in 2019)

Allergies

• No known drug allergies (NKDA)

Family History

The patient reported no significant family medical history.

Surgical History

• Tonsillectomy (1996)

Social History

The patient denied the use of:

• Alcohol

• Tobacco

• Recreational drugs

Current Medications

• Prozac (Fluoxetine) 10 mg orally once daily

• Kyleena IUD (inserted in 2019)

Review of Systems

General

The patient denied fever, fatigue, chills, appetite changes, or changes in activity level.

Cardiovascular

The patient denied chest pain, palpitations, or chest tightness.

Respiratory

The patient denied cough, shortness of breath, or wheezing.

Gastrointestinal

The patient denied:

• Nausea

• Vomiting

• Diarrhea

• Constipation

• Heartburn

Genitourinary

Positive findings included:

• Abnormal vaginal discharge

• Spotting

• Pelvic pain

Negative findings included:

• Increased urinary frequency

• Urinary urgency

• Hematuria

Musculoskeletal

The patient reported intermittent lower back pain.

Physical Examination Findings

Vital Signs

• Blood Pressure: 118/57 mmHg

• Heart Rate: 68 beats per minute

• Respiratory Rate: 16 breaths per minute

• Temperature: 37.1°C

• Oxygen Saturation: 100% on room air

• Height: 5 feet 4 inches

• Weight: 125 pounds

General Appearance

The patient appeared well and was in no acute distress.

Cardiovascular Examination

Cardiovascular examination revealed:

• Regular heart rate and rhythm

• Distinct S1 and S2 heart sounds

• No audible murmurs

Clinical Considerations

Potential Causes of Vaginal Spotting and Discharge With an IUD

Hormonal IUDs can cause irregular bleeding patterns, especially during the first year after insertion. However, new symptoms appearing several years after placement warrant further investigation.

Potential considerations include:

• Hormonal changes associated with IUD use

• Cervical irritation

• Vaginal or cervical infection

• Pelvic inflammatory disease (PID)

• Pregnancy, including ectopic pregnancy

• Endometrial or cervical abnormalities

• IUD displacement or partial expulsion

Recommended Diagnostic Evaluation

Healthcare providers may consider the following assessments:

• Pelvic examination

• Pregnancy testing

• Sexually transmitted infection (STI) screening

• Urinalysis

• Vaginal swab testing

• Pelvic ultrasound to assess IUD placement

• Additional laboratory studies based on clinical findings

Summary

This case highlights the importance of evaluating new-onset vaginal spotting, abnormal discharge, and pelvic discomfort in patients with long-term hormonal IUD use. Although many cases are related to benign hormonal changes, persistent or worsening symptoms should be assessed promptly to rule out infection, pregnancy-related complications, or issues involving IUD placement.

References

American College of Obstetricians and Gynecologists. (2024). Long-acting reversible contraception (LARC): Intrauterine devices and implants. https://www.acog.org/womens-health/faqs/long-acting-reversible-contraception-iud-and-implant

Mayo Clinic. (2025). Hormonal IUD (Mirena). https://www.mayoclinic.org/tests-procedures/mirena/about/pac-20391354

NU569 SOAP Note

Centers for Disease Control and Prevention. (2024). Sexually transmitted infections treatment guidelines. https://www.cdc.gov/std/treatment-guidelines/default.htm

Cleveland Clinic. (2025). Vaginal discharge: Causes, colors, and treatment. https://my.clevelandclinic.org/health/symptoms/4719-vaginal-discharge

Merck Manual Professional Edition. (2025). Evaluation of pelvic pain in women. https://www.merckmanuals.com/professional/gynecology-and-obstetrics