NU569 SOAP Note

Student Name

Purdue University Globle 

NU569 FNP I Clinical – Lifespan Health Focus

Prof. Name

Date

NU569 SOAP Note

New vaginal discharge, spotting, and lower abdominal cramping in a patient with a Kyleena intrauterine device (IUD) should not be ignored, especially when these symptoms develop several years after insertion. Although hormonal IUDs can occasionally cause changes in bleeding patterns, persistent pelvic pain, abnormal discharge, and spotting may indicate infection, IUD displacement, pregnancy-related complications, or other gynecologic conditions that require timely medical evaluation. This NU569 SOAP Note reviews the patient’s presentation, clinical findings, potential differential diagnoses, and recommended diagnostic approach.

Patient Presentation

A female patient presented with concerns of abnormal vaginal discharge, intermittent spotting, and lower abdominal cramping. She reported experiencing lower abdominal cramps for approximately three days and noted spotting once daily for the preceding six days.

The patient has used a Kyleena IUD since 2019 and reported amenorrhea following insertion, with no menstrual bleeding for several years. Before transitioning to an IUD, she used oral contraceptive pills for an extended period, making it difficult for her to identify her baseline menstrual pattern.

The patient described the vaginal discharge as stringy and resembling old blood. She also noted episodes of milky or clear mucus discharge. In addition, she experienced intermittent lower back discomfort.

Her last sexual encounter occurred on a recent Friday with the same sexual partner she has maintained since her sexually transmitted disease (STD) screening in 2019.

Medical History

Gynecologic History

• Last menstrual period (LMP): Unknown

• Previous contraception: Oral contraceptive pills

• 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 products

• Recreational drugs

Current Medications

• Fluoxetine (Prozac) 10 mg orally once daily

• Kyleena IUD (inserted in 2019)

Review of Systems

General

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

Cardiovascular

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

Respiratory

No cough, wheezing, or shortness of breath was reported.

Gastrointestinal

The patient denied:

• Nausea

• Vomiting

• Diarrhea

• Constipation

• Heartburn

Genitourinary

Positive findings included:

• Vaginal discharge

• Intermittent spotting

• Pelvic pain

Negative findings included:

• Urinary frequency

• Urinary urgency

• Hematuria

• Dyspareunia

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: 5’4″

• Weight: 125 lbs

General Appearance

The patient appeared well, alert, and in no acute distress during the examination.

Cardiovascular Examination

Cardiovascular assessment demonstrated:

• Regular rate and rhythm

• Normal S1 and S2 heart sounds

• No murmurs appreciated on auscultation

Clinical Considerations

Potential Causes of Vaginal Spotting and Discharge With a Kyleena IUD

Hormonal IUDs are highly effective forms of long-acting reversible contraception (LARC). However, the development of new gynecologic symptoms several years after insertion warrants a comprehensive evaluation.

Potential etiologies include:

• Hormonal changes associated with long-term IUD use

• Cervical irritation or inflammation

• Vaginal or cervical infections

• Pelvic inflammatory disease (PID)

• Pregnancy, including ectopic pregnancy

• Endometrial or cervical abnormalities

• IUD malposition, displacement, or partial expulsion

Patients living in urban, suburban, or rural communities should seek prompt medical care if symptoms worsen or are accompanied by fever, severe pelvic pain, heavy bleeding, or dizziness, as these findings may indicate a more serious underlying condition.

Recommended Diagnostic Evaluation

Diagnostic Workup

A comprehensive evaluation may include the following:

• Pelvic examination

• Urine or serum pregnancy testing

• Sexually transmitted infection (STI) screening

• Urinalysis

• Vaginal swab testing

• Pelvic ultrasound to confirm IUD placement

• Additional laboratory testing based on clinical findings

Diagnostic imaging is particularly valuable when there is concern for IUD migration, partial expulsion, or ectopic pregnancy.

Clinical Significance

This case emphasizes the importance of assessing new-onset spotting, vaginal discharge, and pelvic discomfort in patients with long-term hormonal IUD use. While many individuals experience minimal side effects with Kyleena, symptoms that arise years after insertion should be evaluated to exclude infectious, structural, or pregnancy-related causes.

Early recognition and appropriate diagnostic testing can improve outcomes and ensure patients receive timely treatment. Healthcare providers should maintain a broad differential diagnosis and consider patient history, symptom progression, and physical examination findings when developing a management plan.

Summary

Abnormal vaginal discharge, spotting, and pelvic cramping in a patient with a Kyleena IUD may represent benign hormonal changes; however, they can also indicate conditions requiring immediate medical attention. A thorough assessment, including pelvic examination, pregnancy testing, STI screening, and imaging when indicated, is essential to identify the underlying cause and guide treatment decisions.

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

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

NU569 SOAP Note

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

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