PLEASE RESPOND TO THE FOLLOWING POSTS WITH 1-2 PARAGRAPHS
PLEASE RESPOND TO THE FOLLOWING POSTS WITH 1-2 PARAGRAPHS
POST 1
Lisa is a 19-year-old female who presents to the clinic c/o abnormal vaginal discharge for one week after having unprotected vaginal intercourse with a new male partner she has been dating for a couple of weeks. Lisa’s pregnancy test is negative and her LMP was 2 weeks ago. As her health care provider, you will need to perform testing to determine if Lisa has contracted a sexually transmitted infection or other vaginal infection.
Chief Complaint: Abnormal vaginal discharge for one week
HPI: This is a 19 y/o F presenting to the clinic today with abnormal vaginal discharge for one week after having unprotected vaginal intercourse with a new male partner. The pregnancy test in the office is negative. She reported her LMP 2 weeks ago.
PMH:
Medical- no past medical history
Surgical- no past surgical history
Hospitalizations- no past hospitalizations
Allergies- NKDA
Immunizations- Up to date on Immunizations
Social History- She is currently sexually active with new partners with whom she has been seeing for two weeks.
Current Medications:
No current medications
Review of Systems (ROS):
Systemic: Negative for malaise, fever or chills
HEENT: Negative for headache, sinus congestion or vision changes.
GI: Positive for abdominal pain and tenderness.
GU/ Reproductive: Positive for dysuria, vaginal discharge, burning with urination, vaginal irritation. Patient denies history of STIs. Denies multiple sex partners.
Skin: Denies lesions, rash, and open wounds.
Neuro/psych: Denies mood changes and suicidal ideations.
Objective/Assessment
Temp: 98.5 F, Blood Pressure: 124/78 mm Hg, HR: 78/min, RR: 19/min, BMI: 25.42 Index, Ht: 62 in, Wt: 139 lbs, Oxygen sat %: 97 on room air
Systemic: Well-nourished and in no acute distress.
HEENT: Normocephalic, PERRLA
GI: Abdomen is soft and tender on palpation.
GU/ Reproductive: Internal genitalia with creamy thick and malodorous discharge.
(Diagnosis/ICD10 Code/Plan )
A64 Unspecified sexually transmitted disease
Plan: Wet prep, DNA probe to rule out STI. Urinalysis and culture to rule out UTI.
Treatment: Flagyl 500 mg PO BID for seven days of culture results come back positive for common STIs such as Trichomonas. Doxycycline 100mg orally BID for 7 days if positive for chlamydia.
Education: Educated patient on safe sex practices and using barrier methods for reducing the risk of STIs. Educated patient on potential complications associated with STIs such as the development of PID. Educated patient that her partner may need to be treated and tested for STI. Patient also educated on remaining abstinent during treatment course.
References:
A guide to taking a sexual history. (2023). https://www.cdc.gov/std/treatment/sexualhistory.ht…
FAAN, I.M.A.P.A.A. F. (2023). Women’s Healthcare in Advanced Practice Nursing (3rd ed.). Springer Publishing LLC. https://online.vitalsource.com/books/9780826167224
U.S. Centers for Disease Control and Prevention (CDC), California Department of Public Health (CDPH), & American College of Obstetricians and Gynecologists (ACOG). (2023). Screening guidelines for sexually transmitted infections (STIs), viral hepatitis, and tuberculosis (TB) in California Correctional/Detention Facilities [Report]. https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20D…
POST 2
CC: Tina is a 27-year-old female who presents to the clinic complaining of a painful burning sensation in her left labial area for 3 days. She reports recently having unprotected vaginal intercourse with a new male partner. Upon examination, you note fluid-filled vesicles on the left labia minora that are painful to touch.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
Subjective:
ROS
CONSTITUTIONAL: denies fever, chills, fatigue
NECK: denies painful or swollen nodes.
ENDOCRINE: denies tremor/palpitations/heat or cold intolerance/unusual fatigue; denies polyuria/polydipsia/polyphagia
RESPIRATORY: denies cough/sputum/SOB/chest pain.
CARDIOVASCULAR: denies CP/SOB/palpitations/edema.
GASTROINTESTINAL: denies constipation/nausea/vomiting/diarrhea/blood in stool.
BREASTS: denies pain/tenderness/lumps/masses/nipple discharge.
GENITOURINARY: denies dysuria/frequency/vaginal bleeding/blood in urine/incontinence/abnormal vaginal discharge/vaginal dryness/dyspareunia
Confirms painful burning sensation in her left labial area for 3 days;
Ask about smoking, drinking, and drug use.
Ask about how many partners she has and sexual habits.
Ask about pattern of period.
Ask about STIs.
Ask about what she does for work.
Ask if she feels safe.
Ask when her last PAP smear was.
Ask if she has any kids.
Inquire about any recent weight changes, stressors, or lifestyle modifications that could contribute to irregular menstrual cycles.
Assess for any menstrual pain or discomfort associated with oligomenorrhea.
PSYCHIATRIC: denies depression/anxiety.
OBJECTIVE
Vitals:
WNL
EXAM
GENERAL: Well-developed, well-nourished, alert and cooperative, and appears to be in no acute distress.
NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.
CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits.
LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds.
BREASTS: No masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy.
PELVIC: Normally developed external female genitalia with fluid filled vesicles on the L labia – painful to touch.
Explain what POCT you will you order and perform and discuss your rationale for ordering and performing each test.
- A direct swab of vesicular lesions (within 72 hours of onset) (Mathew & Sapra, 2023)
- HSV serotyping (Mathew & Sapra, 2023)
- Gonorrhea and chlamydia (Mathew & Sapra, 2023)
- HIV (Mathew & Sapra, 2023)
- Pregnancy test (Mathew & Sapra, 2023)
Rationale: A direct swab of the vesicular lesions can provide a more accurate result compared to HSV serotyping as the HSV serotyping detects for antibodies making it hard to create a timeline of the infection. It’s important to also test for G&C and HIV because it can co-exist.
Assessment/ Diagnosis:
Diagnosis: ICD 10 B00 – Herpesviral infections
Rationale: The patient presents with what seems as a primary infection with painful genital ulcers and sores which are signs of HSV2. She also stated that she has a new partner, which increases risk of new STIs (Mathew & Sapra, 2023).
Any other diagnosis or differential diagnosis you would like to add?
Diffrential diagnosis:
Syphilis
Chancroid
Plan:
What will you prescribe for this patient? Why? (assume one of your lab test results is positive)
- Acyclovir
Primary herpes genitalis: 3 x 400 mg tablets PO daily for 7 to10 days (Mathew & Sapra, 2023).
This medication is an antiviral that has low side effecs and can be tolerated for long periods of time. This suppressive treatment can prevent or delay 80% of recurrences and reduce shedding by greater than 90% (Mathew & Sapra, 2023).
Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s), partner notification, and follow-up plan of care.
Educate the patient about potential side effects, including nausea, headache, and dizziness (Mathew & Sapra, 2023). Advise her to notify you if any adverse reactions occur. Partner notification: Encourage Tina to inform her recent sexual partner about her diagnosis, as they may also require testing and treatment.
Return to clinic if symptoms do not resolve with medication.
What patient education is important to include for this patient? (Consider when can the patient resume sexual activity)
Provide information about safe sex practices, including condom use to reduce the risk of transmission (Mathew & Sapra, 2023). Advise Tina to abstain from sexual activity until the lesions have healed completely and symptoms have resolved (Mathew & Sapra, 2023).
Explain complications that can occur if patient does not comply with treatment regimen.
Please refer to evidence-based guidelines to support your decision-making.
Tina should complete the full course of antivirals to prevent recurrent outbreaks and complications. Educate patient on safe sex practices to avoid spreading (Mathew & Sapra, 2023).
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