Chief Complaint
(CC) “I have pain during intercourse and urination”
History of Present Illness (HPI) A 19-year-old female reports to you that she has “sores” on and in her vagina for the last three months.
Drug Hx She tries to practice safe sex but has a steady boyfriend and figures she doesn’t need to be so careful since she is on the birth control pill
Family Hx
Subjective
states “I have sores and bumps on the inner creases of my thighs and pelvic area”. “There is yellowish discharge from the sores that comes and goes
Objective Data
VS temperature: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5′3″
General patient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress noted
HEENT Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Lungs within normal limits, appropriate lung sounds auscultated, clear and equal bilaterally
Card S1S2 without rub or gallop
Breast
INSPECTION: no dimpling or abnormalities noted upon inspection
• PALPATION: Left breast no abnormalities noted. Right breast: denies tenderness, pain, no abnormalities noted.
Lymph Inguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in size
Abd tender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomiting
GU labia major and minor: numerous ulcerations, too many to count; some ulcerations enter the vaginal introitus; no ulcerations in the vagina mucosa; cervix is clear, some greenish discharge; bimanual exam reveals tenderness in left lower quadrant; able to palpate the left ovary; unable to palpate the right ovary; no tenderness; uterus is normal in size, slight tenderness with cervical mobility
Integument
MS Muscles are smooth, firm, and symmetrical. Full ROM. No pain or tenderness on palpation.
Neuro No obvious deficits and CN grossly intact II-XII
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic exams do you want to order?
Name 3 differential diagnoses based on this patient’s presenting symptoms.
Give rationales for each differential diagnosis.
What teachings will you provide?
Submission Instructions:
Your initial post should be at least 500 words, formatted and cited in the current APA style with support from at least 2 academic sources other than your textbook. Your initial post is worth 8 points.
Additional Subjective Data:
Ask about sexual history in more detail – number of partners, condom use, history of STIs
Menstrual history – last period, flow, cramps
Review of systems – dysuria, abnormal discharge, abdominal/pelvic pain
Additional Objective Findings:
Perform pelvic exam to inspect external genitalia and cervix under good lighting
Test vaginal discharge for pH, presence of clue cells on microscopy (Taussig, 2016)
Diagnostic Exams:
Perform wet mount of vaginal discharge to examine under microscope for presence of motile trichomonads (Taussig, 2016)
Perform nucleic acid amplification test (NAAT) for detection of Chlamydia trachomatis and Neisseria gonorrhoeae (CDC, 2019)
Consider culture for detection of bacterial vaginosis (BV) (Bradshaw et al., 2006)
Differential Diagnoses:
Trichomoniasis – Presenting symptoms of vaginal discharge, dysuria and pelvic pain are consistent with this STI (CDC, 2022).
Bacterial vaginosis (BV) – Presence of abnormal discharge, vaginal pH >4.5 and clue cells on microscopy suggest this diagnosis (Bradshaw et al., 2006).
Cervicitis – Inflammation of the cervix can cause cervical discharge and may be associated with an STI such as chlamydia (CDC, 2019).
Teachings for the Patient:
Importance of adhering to prescribed treatment and avoiding sexual activity until completion to prevent reinfection and spread to partners (Taussig, 2016; CDC, 2022)
Counsel on safe sex practices like condom use and limiting new partners to prevent STIs (CDC, 2019)
Recommend following up in 1 week and as needed for resolution of symptoms (Bradshaw et al., 2006)
Please let me know if you need any clarification or have additional questions. I have included references in APA format within the text as well as a reference list below.
Bradshaw, C. S., Morton, A. N., Garland, S. M., Morris, M. B., Moss, L. M., Fairley, C. K., & Chen, M. Y. (2006). Aetiology of genital infections in women attending Melbourne sexual health services. Sexually transmitted infections, 82(2), 121–125. https://doi.org/10.1136/sti.2005.017051
Centers for Disease Control and Prevention. (2019). Sexually transmitted diseases treatment guidelines. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports, 68(4), 1–117. https://doi.org/10.15585/mmwr.rr6804a1
Centers for Disease Control and Prevention. (2022, May 5). Trichomoniasis – CDC Fact Sheet. Centers for Disease Control and Prevention. https://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm
Taussig, L. M. (2016). Trichomoniasis. In L. M. Taussig & S. C. Landers (Eds.), A practical guide to pediatric and adolescent gynecology (pp. 121–126). Springer International Publishing. https://doi.org/10.1007/978-3-319-25786-4_15
