Differential Diagnosis

• Single most likely diagnosis
  • D) Genito-pelvic pain/penetration disorder: This diagnosis is the most likely because the patient experiences pain and vaginal muscle spasms during attempts to insert a speculum, which is a key characteristic of genito-pelvic pain/penetration disorder. The patient's concerns about having a sexual relationship with her boyfriend and her inability to undergo a pelvic examination due to pain and muscle spasms further support this diagnosis.
• Other Likely diagnoses
  • B) Female sexual interest/arousal disorder: Although the patient is interested in being more intimate with her partner, her primary concern is the pain and difficulty with penetration, which might also suggest a potential issue with sexual interest or arousal. However, this is not the primary complaint.
  • A) Adjustment disorder with anxiety: The patient reports anxiety related to her concerns about having a sexual relationship, which could be considered an adjustment disorder. However, the primary issue seems to be related to the physical and sexual aspects rather than a broader adjustment issue.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • None of the options provided directly point to a condition that would be immediately life-threatening if missed. However, it's essential to consider underlying conditions that could cause similar symptoms, such as:
    • Physical obstruction or anatomical abnormalities: Though not listed among the choices, conditions like imperforate hymen or other anatomical issues could cause similar symptoms and would be crucial to identify.
• Rare diagnoses
  • E) Vulvodynia: While vulvodynia could cause pain, the specific issue with penetration and the absence of other symptoms like chronic pain or burning suggest that this is less likely. Vulvodynia is characterized by chronic pain in the vulva without an identifiable cause, which doesn't perfectly match the patient's presentation focused on penetration difficulties.
  • C) Generalized anxiety disorder: This diagnosis seems less relevant as the patient's anxiety is specifically related to her concerns about sexual intercourse and not generalized across multiple aspects of her life.