Demographic Data

POST 1 

Case Scenario

Demographic Data

• Chief Complaint (CC): “I have been experiencing abnormal vaginal discharge for the past one week.”
• History of Present Illness (HPI): L.G., a 19-year-old African American female patient, presents to a primary healthcare provider complaining of experiencing abnormal vaginal discharge for the past week. The patient reported that the onset of the discharge started one week ago. The vaginal discharge has been persistent for the last one week, although it has been worsening daily. The patient describes the abnormal vaginal discharge as being thin, watery, and grayish-white in color with a fishy smell. She also reports experiencing pelvic pain and painful urination. She believes that the condition is aggravated by practicing unprotected vaginal intercourse with a new male partner. The patient is unaware of any relieving factors since she has not attempted any intervention to manage the vaginal discharge. The discharge has been continuous since its onset, a few days after engaging in unprotected sexual activity. Her general health condition is good other than the chief complaint she presents.
• PAST MEDICAL HISTORY: No history of vaginal infection
• PAST SURGICAL HISTORY: No previous surgical procedures

FAMILY HISTORY: Lisa’s paternal grandmother has a history of cervical cancer. No family member has a history of a health issue related to the genitourinary system.

CURRENT MEDICATIONS: She does not use any medications currently

ALLERGIES: NKA

IMMUNIZATIONS HISTORY: She was immunized with influenza eight months ago

HEALTH MAINTENANCE

• Pap Smear: Not yet, since she has not attained the recommended age

Urine Microalbumin: Not yet

• Diet/Lifestyle Changes: Not yet

SOCIAL HISTORY: L.M. is the firstborn daughter in a family of three children. They all live with their parents. She completed her high school studies the previous year, although she had not joined any institution of higher learning. She has been sexually active for the past one year. She engages in both unprotected and protected sexual activity with multiple male partners. She reports previous foul-smelling vaginal discharge, although she has never sought medical attention. She is currently sexually active with a new male partner, and she engaged in sexual activity a week ago. She does not have children. She has a regular menstrual cycle. She denies pain during sexual practice and reports pelvic pain and painful urination. Her hobby is socializing and making new male friends who eventually become sexual partners for a short period. She eats both healthy and unhealthy diets.

• REVIEW OF SYSTEMS:

General: Lisa denies fever, fatigue, and weight loss

• Gastrointestinal: She denies abdominal pain and vomiting

Genitourinary: She reports pelvic pain, abnormal discharge, and painful urination

• Endocrinology: She denies abnormal urination and heat/cold intolerance

PHYSICAL EXAMINATION:

• Vital Signs: Blood pressure: 120/80mmHg, heart rate: 88bpm, respiratory rate: 19bpm, and temperature: 370C

Genital/Rectal:

• Vaginal discharge: Thin, grayish-white, watery discharge noted

Vaginal Odor: A distinct fishy odor is noted

• Vaginal Wall Appearance: The vaginal walls may appear erythematous (red)
• Differential Diagnosis (DDx)
• Trichomoniasis (ICD10: A59.9): This refers to an STI associated with the parasite Trichomonas vaginalis. Some symptoms experienced include frothy-foul-smelling discharge, burning sensation, and itchiness (Muzny et al., 2022). Some risk factors that contribute to the infection include multiple sex partners and frequent sexual activity. Although L.M. experiences the mentioned aspects, the description of her vaginal discharge is inconsistent with that of trichomoniasis, thus making this condition an unlikely diagnosis.

Working Diagnosis

Bacterial Vaginosis (BV) (ICD 10:N76.1): Bacterial vaginosis is an infection that develops when there is an imbalance of vaginal bacteria. The infection is characterized by various symptoms such as irritation, fishy-smelling discharge, and itching (Abou Chacra et al., 2022). Some risk factors that contribute to the infection include multiple sex partners and frequent sexual activity. The vaginal discharge that an individual with this infection experiences is usually considered as thin, grayish-white, watery discharge with a distinct fishy odor. Since L.M.’s description of her chief complaint and associated aspects are consistent with those of BV, this condition is likely the primary diagnosis.

Treatment (Tx) Plan:

Diagnostic Tests:  Order a point-of-care testing (POCT) to confirm the diagnosis using a whiff test or vaginal pH test

Pharmacologic Treatment: Prescribe metronidazole 500mg orally twice daily for seven days

• Patient Education:

Educate the patient on practicing safer sex practices using a barrier such as a condom (Abou Chacra et al., 2022)

• Inform the patient to complete the entire course of antibiotics for effective outcomes

Referral/Follow-up:

• A referral is not required at the moment

Schedule a follow-up visit after one week for reassessment

• References

Abou Chacra, L., Fenollar, F., & Diop, K. (2022). Bacterial vaginosis: What do we currently know? Frontiers in cellular and infection microbiology, 11, 672429. https://doi.org/10.3389/fcimb.2021.672429

Muzny, C. A., & Van Gerwen, O. T. (2022). Secnidazole for trichomoniasis in women and men. Sexual Medicine Reviews, 10(2), 255-262. https://doi.org/10.1016/j.sxmr.2021.12.004

POST 2 

CC: “I have a painful burning sensation in my left labial area.”

• HPI: Tina, a 27-year-old female, presents with a 3-day history of a painful burning sensation on her left labia minora. She notes the onset of symptoms occurred shortly after unprotected vaginal intercourse with a new male partner. Upon further questioning, Tina mentioned the presence of fluid-filled vesicles in the same area which are painful to touch. 

Medications: None reported. Confirmed no use of over-the-counter products or herbal supplements that might affect immune function or skin integrity.

• Allergies: NKDA

LMP: Approximately two weeks ago, described as normal without any unusual pain or abnormal bleeding.

• Gyn/OB history: G1P0, with one therapeutic abortion at age 25. No other pregnancies or gynecological interventions. Regular menstrual cycles typically last 4 days, except for the current presentation.

PMH: No significant illnesses or surgeries were reported. No known chronic diseases.

• Chronic Illness/ Major trauma: None Reported

Family Hx: Father is alive age 58 with Hypertension. Mother alive age 54 with Type 2 diabetes. Two younger brothers age 24 and age 20, are healthy. no known genetic diseases, and no reported history of cancers, specifically gynecological cancers, which could predispose to higher risk profiles.

• Social Hx: Tina identifies as bisexual and is currently in a new relationship with a male partner. Previously had relationships with both men and women. She is employed as a loan officer, suggesting a potentially stressful work environment. Lives in Los Angeles. Denies tobacco, or drug use. Reports drinking a couple of glasses of vodka occasionally. Reports a vegan diet, which could have implications for her general nutrition status. She reports being active but has been absent lately. She currently, goes for walks 30 mins 2 to 3 times a week.

Review Of System: 

General: Reports fatigue and denies fever, or weight loss.

Integumentary: Reports isolated vesicular lesions on the left labial minora.

Cardiovascular: Denies chest pain or palpitations.

• Respiratory: Denies cough or shortness of breath.

GI: Denies nausea, vomiting, or diarrhea.

Gynecological: Reports painful vesicles on the labia, denies abnormal vaginal discharge or odor, and pelvic pain outside of described lesions. Denies bleeding in between periods.

Additional Questions: 

What other relevant questions should you ask regarding the HPI?

• When did you first notice the symptoms starting exactly? 

Can you describe the pain? Is it more of a burning sensation, a sharp pain, a dull pain, or something else?

How severe is the pain on a scale of 1-10, and how is it affecting your daily activities?

Can you point to where exactly you feel the pain? Is it localized to one spot or does it spread to other areas?

How long does the pain last? Does it come and go or is it constant?

• Does anything make the pain worse such as walking, urinating, or during sexual activity?

Is there any particular time of day when the pain is more intense? Has the frequency of the pain episodes increased since it first began

• Have you noticed any other symptoms associated with the pain, such as fever, swelling, lower abdominal pain, unusual vaginal discharge, malaise or an increase in the number of lesions? 

Have the lesions changed in size, color, or shape since you first noticed them?

• Have you tried any treatments or home remedies since the symptoms began? If so, what were they and did they provide any relief?

Have you experienced similar symptoms in the past?

• What other medical history questions should you ask?
• Have you ever been diagnosed with any sexually transmitted infections (STIs) or other infectious diseases?
• Do you have any chronic health conditions, such as diabetes or an autoimmune disorder?

Are you currently taking any medications, including over-the-counter drugs, prescriptions, or supplements?

• Have you undergone any surgeries or hospitalizations in the past?
• Are you allergic to any medications, foods, or other substances?

What other social history questions should you ask?

Can you tell me more about your sexual history, including the number of partners you’ve had and the type of relationships?

Do you use protection during sexual intercourse, such as condoms or dental dams? How consistently do you use protection?

What is your occupation, and are there any occupational hazards that could affect your health such as exposure to chemicals or physical stress?

What is your level of daily stress and how do you manage it?

Who do you consider part of your support system during health issues?

What is your current relationship status, and how long have you been with your current partner?

Do you use tobacco, alcohol, or other recreational drugs? If so, how often and in what quantities?

What does your typical diet look like, and do you follow any specific dietary restrictions?

Does your partner have any symptoms or known sexually transmitted infections?

Objective:

General Appearance: Alert and oriented x3, appears in mild distress due to pain.

Vital Signs: Blood Pressure: 120/78 mmHg, Heart Rate: 76 bpm, Temperature: 98.6°F 

Respiratory Rate: 16 breaths per minute

Physical Exam:

Cardiac: Regular rate and rhythm. No murmurs, rubs or gallops.
Respiratory: Chest rise is equal and symmetric. Unlabored. Lungs clear to auscultation bilaterally.

Abdominal: Soft, non-tender, non-distended. Bowel sounds normal.

Integumentary: No rashes or lesions noted elsewhere. Inspection of the genital area reveals fluid-filled vesicles on the left labia minora, painful on palpation.

Genitourinary: No costovertebral tenderness
Gynecological: No urethral discharge, no lesions, no muscle tenderness. 

Labia: vesicles noted on the labia are indicative of an active lesion

Vagina: vaginal mucosa without discharge, and no foul odor;  no lesions, no bleeding
Cervix: No cervical motion tenderness or adenopathy, no discharge.
Uterus: Within normal limits, not enlarged, not tender

POCT (Point of Care Testing):

HSV (Herpes Simplex Virus) PCR swab of the lesions to confirm HSV infection. This test is rapid and specific for diagnosing HSV which correlates with the clinical presentation of genital herpes. (Zhu & Viejo-Bordolla, 2021).

HSV PCR Swab: A swab of the vesicular fluid will be taken and tested using the Polymerase Chain Reaction (PCR) method. HSV PCR is the gold standard for diagnosing herpes simplex virus infections due to its high sensitivity and specificity. It can accurately differentiate between HSV-1 and HSV-2, which is essential for proper management and counseling. This test is rapid and specific for diagnosing HSV which correlates with the clinical presentation of genital herpes (Zhu & Viejo-Bordolla, 2021). Positive results will confirm the diagnosis of genital herpes and help in initiating the correct antiviral treatment promptly to alleviate symptoms and reduce the duration of the outbreak (Zhu & Viejo-Bordolla, 2021).

Rapid HIV Test: A rapid HIV antibody/antigen test using a blood sample from a finger prick. Given Tina’s High-Risk Sexual Behavior and history of unprotected sex with a new partner, assessing her HIV status is critical. Rapid tests provide results in 30 minutes, which aids in immediate counseling and further planning. It is also important to screen for Co-infections because patients with one STI often have or are at risk for others, including HIV. Early detection in the clinical setting can significantly impact patient outcomes. It can give the patient some peace of mind. Providing rapid results can reduce anxiety and ensure patient cooperation with follow-up recommendations (Huynh, & Kahwaji, 2023).

Urine Pregnancy test: A qualitative hCG test using a urine sample to rule out pregnancy.  Before starting any medication, particularly antivirals or antibiotics that may have teratogenic effects, confirming pregnancy status is crucial. POCT for pregnancy provides quick results, aiding in decision-making regarding the safety and appropriateness of prescribed medications (Nwabuobi, et al., 2017).

RPR (Rapid Plasma Reagin) Test: To rule out syphilis, an RPR test may be conducted if the examination suggests any atypical features that could align with a syphilis infection.

Assessment/Diagnosis:

Primary Diagnosis: 

Genital Herpes (Herpes Simplex Virus, Type 2) ICD-10: A60.9

Tina presents with classic symptoms of genital herpes, including painful, fluid-filled vesicles on her labia, which developed after unprotected sexual intercourse, a typical mode of transmission for herpes simplex virus. The localized pain, burning sensation, and the appearance of the vesicles strongly suggest an HSV infection, likely type 2, given its prevalence in genital infections (Zhu & Viejo-Bordolla, 2021). Her other positive symptoms such as high levels of stress due to work and feeling fatigued can also be attributed to this infection.

Differential Diagnosis:

Herpes Simplex Virus, Type 1 ICD-10: Boo.9

HSV-1, typically associated with oral herpes, can also cause genital herpes through oral-genital contact. Considering the increasing incidence of genital herpes caused by HSV-1, it remains a possible cause of her symptoms, particularly if her recent partner had oral herpes (Zhu & Viejo-Bordolla, 2021).

Syphilis (Primary) ICD-10: A51.0

Primary syphilis presents with a chancre typically a single, painless ulcer, which can occasionally be painful or multiple. While less likely, it should be considered given the sexual history and the potential for atypical presentations (Huynh, & Kahwaji, 2023).

Contact Dermatitis ICD-10: L23.9

This could occur due to exposure to irritants or allergens, such as lubricants, condoms, or spermicides. It typically presents with itching and redness, but blistering can occur in severe cases. It’s a less likely diagnosis given the presentation but should be considered if the lesions do not have a viral appearance on further examination or if treatment for HSV does not resolve the symptoms (Dunphy et al., 2022).

Plan:

Diagnostic Tests:

Herpes Simplex Virus (HSV) PCR from lesion swabs to confirm the presence of HSV and determine the type HSV-1 or HSV-2.

Rapid HIV Test: Given the unprotected sexual encounter, it’s prudent to screen for HIV to rule out co-infections.

Lab Tests:

Full STI Panel: Including tests for chlamydia, gonorrhea, syphilis, and hepatitis B and C, to ensure comprehensive sexual health screening and address any other potential infections (Baldh, 2015).

Treatment:

Medication:

Valacyclovir 1 g orally twice daily for 7 days for acute outbreak management. This is the first-line treatment for initial outbreaks of genital herpes. This antiviral medication helps to decrease the severity and length of the outbreak, reduce the frequency of recurrence, and minimize the risk of virus transmission (Albrecht et al., 2024).

Referrals:

• Referral to a gynecologist for follow-up and further evaluation as needed.
• If outbreaks are frequent or severe, a referral to an infectious disease specialist or a dermatologist specializing in viral infections might be necessary for advanced management (Albrecht et al., 2024).
• Counseling Services: Considering the psychological impact of a herpes diagnosis, referral to a counselor or therapist specializing in chronic illness management might be beneficial for Tina.
• Education:
• Educate Tina about the nature of herpes as a chronic, manageable condition. Discuss how it’s transmitted, signs of outbreaks, and implications for future sexual health along with the potential for recurrent episodes (CDC, 2021).
• Transmission Prevention: Stress the importance of using condoms and avoiding sexual contact during outbreaks to prevent spreading the virus to partners (CDC, 2021).
• Symptom Management: Educate on recognizing early signs of outbreaks and managing symptoms at home, such as keeping affected areas clean, and dry, and using pain relief measures. Discuss with her the potential transmission even when asymptomatic (Dunphy et al., 2022).
• Health Maintenance:
• Vaccine Review: Ensure Tina is current on all relevant vaccinations, including Hepatitis B, if her screening results show she hasn’t been vaccinated or previously infected. Encourage routine gynecological exams and regular STI screenings as part of ongoing health maintenance (CDC, 2021).
• Follow Up:
• Schedule a follow-up appointment in 1-2 weeks to assess response to the medication and discuss any concerns post-diagnosis.
• Arrange regular follow-ups every 3-6 months to monitor her condition, manage recurrences, and adjust treatment plans.
• Routine gynecological examination annually or as recommended.
• Provide instructions on when and how to seek immediate medical attention if symptoms significantly worsen or she experiences complications such as extremely painful lesions or signs of secondary bacterial infection.
• Prompt Questions’ Answers
• Assuming the lab test confirms a positive result for Herpes Simplex Virus Type 2 (HSV-2), the following medications and treatments would be recommended:
• Antiviral Therapy:
• Valacyclovir 500 mg orally twice daily for 7-10 days for an initial outbreak. If recurrent outbreaks are frequent, consider daily suppressive therapy.
• Why Valacyclovir? It is effective in reducing the duration and severity of the symptoms. It helps heal the sores faster, prevents new sores from forming, and decreases pain/itching. This medication can also help reduce the risk of the virus spreading to others (CDC, 2021)..
• Treatment Guidelines and Side Effects:
• Side Effects: Common side effects include headache, nausea, stomach pain, vomiting, or dizziness. More serious side effects, though rare, can include kidney problems, a decrease in blood cells, and neurological issues (Woo, 2019).
• Guidelines: According to the CDC, antiviral medications like Valacyclovir are recommended for the treatment of genital herpes. These medications can be used for episodic treatment or daily suppressive therapy depending on the frequency and severity of outbreaks (CDC, 2021).
• Partner Notification:
• Tina needs to inform her sexual partner(s) about her HSV-2 status so they can also get tested and receive counseling on risk reduction.
• Complications of Non-Compliance:
• Increased Risk of Transmission: Non-compliance with treatment and preventive measures increases the risk of spreading the virus to sexual partners(CDC, 2021).
• Worsening Symptoms: Inadequate treatment can lead to more severe and prolonged outbreaks.
• Psychosocial Impact: Recurrent and untreated outbreaks can lead to significant emotional distress and impact sexual and psychological well-being (CDC, 2021).

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