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Please 2 responses , 2 APA REferences each 

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Response 1

Patient Information:

CB, 22 years old, Female

S.

CC (chief complaint): Burning with urination and a discharge with a fishy odor for 3 days.

HPI: CB is a very pleasant 22 year old female, G0P0, who presents to the clinic today for burning with urination and fishy discharge for 3 days. She states she has a new boyfriend and they are having unprotected intercourse. She denies any other partners besides him.  Her medical history is remarkable for anxiety and depression.  Her surgical history is unremarkable. Her social history includes social alcohol, but she denies tobacco and any recreational drugs.  She has no known drug allergies and takes a multivitamin and Sprintec daily for oral contraception.

Current Medications: Multivitamin- daily. Sprintec- daily.

Allergies: No known drug allergies

PMHx: History of anxiety and depression.  

Soc & Substance Hx: Admits to social alcohol use, but denies tobacco or recreational drug use.

Fam Hx: Mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia.  Charlene has one brother with no medical history.

Mental Hx: History of depression and anxiety. Treatment unknown.  

Violence Hx: Unknown Reproductive Hx: Unknown Surgical Hx: Denies any surgical history.

ROS: See HPI.

O.

Height 5’ 5” Weight 148 (BMI 24.6), BP 132/68 P 62

Physical exam:

HEENT:  WNL

Neck: lymph nodes grossly normal

Lungs/CV: Chest is clear to auscultation bilaterally, with normal respiration, rhythm, and depth upon exam

Breast: normal breast exam

Abd: suprapubic tenderness

VVBSU: WNL

Cervix: firm, smooth, copious amounts of green discharge present

Uterus: RV, mobile, non-tender

Adnexa: WNL

Diagnostic results: microscopic evaluation of vaginal fluid (wet mount) shows trichomonas (motile organisms)

A.

Primary and Differential Diagnoses

            Trichomoniasis vaginalis (A59. 01)

Trichomoniasis vaginalis is a common protozoan infection that commonly causes symptomatic vaginitis (Schumann & Plasner. 2022.). Trichomonas thrives in the urogenital tract lumen and secretes cytotoxic proteins that damage the epithelial lining, increasing vaginal pH (Schumann & Plasner. 2022.). Women with a Trichomoniasis infection present with symptoms such as yellow or green discharge with a foul odor, urinary frequency, dysuria, vulvar pruritus, pain during intercourse, vaginal itching, or pelvic pain (Schumann & Plasner. 2022.). Identification and treatment is imperative as complications from Trichomonas vaginalis include increased risk of HIV and complications during pregnancy (Schumann & Plasner. 2022.). Treatment involves either a one-time dose of 2 grams of Metronidazole or 500mg twice a day for 7 days (Cenkowski et al. 2022.). 

Pelvic Inflammatory Disease (N73. 9)

            Pelvic Inflammatory Disease (PID) is the upward inflammation of the upper genital tract, involving the uterus, fallopian tubes, and sometimes the ovaries. Severe cases of PID are associated with the presence of a sexually transmitted infection, and usually affects women ages 15 to 25 years old. When the female upper genital tract becomes infected, scarring, adhesions, and partial or total obstruction of the Fallopian tubes will occur. This damage may lead to a reduction in the number of ciliated epithelial cells in the lining of the Fallopian tube, which results in a disruption in the ovum transport, increasing the risk for infertility, ectopic pregnancy, and chronic pelvic pain. Common symptoms of PID include lower abdominal pain, vaginal discharge, and vaginal bleeding. Diagnosis is confirmed by the presence of lower genital tract inflammation such as cervical discharge, a large number of white blood cells on wet prep, and cervical friability. The primary choice for outpatient treatment is Doxycycline 100mg twice a day for 2 weeks alongside an intramuscular dose of Ceftriaxone 500mg (Jennings & Krywko. 2023.). 

Bacterial Vaginosis (N77. 1)

            Bacterial vaginosis (BV) is an overgrowth of the normal vaginal flora, commonly affecting women of reproductive age (Kairys & Garg. 2022.). BV is described by a marked decrease in the number of Lactobacili and replaced with other bacteria such as Gardnerella vaginalis (Kairys & Garg. 2022.). The other bacteria create a biofilm that serves as a breeding ground for other bacteria to grow within the vagina (Kairys & Garg. 2022.). Women with BV may present asymptomatically or with a fishy discharge that may worsen after sexual intercourse, accompanied by dysuria and vaginal pruritus (Kairys & Garg. 2022.). Diagnosis often occurs by guidance of the Amsel criteria, where 3 of the 4 characteristics need to be present- a thin white/yellow homogenous discharge, presence of clue cells on microscopy, increase vaginal pH, and the presence of a fishy odor (Kairys & Garg. 2022.).  Primary choices of treatment include oral Clindamycin or intravaginal or oral Metronidazole (Kairys & Garg. 2022.).

P.             

            Diagnostic Testing

            The diagnostic testing that should be ordered are the OSOM Trichomonas Rapid Test and the Aptima T. Vaginalis assay (Van Gerwen & Muzny. 2019.). The rapid test is a qualitative antigen-detection assessment that takes about 10-15 minutes to run, uses vaginal specimens, and has a sensitivity of 83-92% and a specificity of 99% (Van Gerwen & Muzny. 2019.). This rapid test is deemed beneficial because it does not require additional laboratory equipment and is cost efficient (Van Gerwen & Muzny. 2019.). The Aptima T. Vaginalis assay may be done if the rapid test is inconclusive. The Aptima T. Vaginalis assay is a NAAT that identifies a target rNA using a transcription-mediated amplification (Van Gerwen & Muzny. 2019.). The assay has a sensitivity of 88-100% and specificity of 98-100%, takes less than 8 hour to run, and may use vaginal or endocervical specimens, urine samples, and ThinPrep specimens (Van Gerwen & Muzny. 2019.).

            Treatment Options

            According to Van Gerwen & Muzney (2019), the CDC recommends a one-time dose of Metronidazole 2g PO for women without a history of HIV. On the other hand, the CDC recommends a regimen of Metronidazole 500mg PO BID for 7 days for women with a history of a HIV infection (Van Gerwen & Muzny. 2019.). Although the latter recommendation is for women with HIV, it is likely it will be the recommended treatment for all women in the future (Van Gerwen & Muzny. 2019.). I would recommend the Metronidazole 500mg PO BID for 7 days.

            Follow Up- Recommend follow up in 2 weeks if symptoms worsen or persist.

            Patient Education

            If prescribing Metronidazole, educating patients to complete the prescribed course of antibiotics is imperative for resolution of Trichomoniasis. Furthermore, patients should be educated to refrain from alcohol use while taking Metronidazole. As providers, encouraging the patient with trichomoniasis to share their diagnosis with their partner and to have their partner tested is essential. Encouraging patients with Trichomoniasis to abstain from sex until resolution of symptoms and course of medications has finished. Encourage patient to continue routine pap smears.

            Reflection

            I have learned a few things from these scenarios we have been presented with. I have learned the importance of maintaining a non-judgmental approach when attempting to speak to women about their health. Maintaining a non-judgemental approach as well as an open mind help encourage a safe space for women to speak about their concerns and ask their question. I have also learned that education is key to the prevention of STIs, women maintaining their health (i.e. pap smears), and can facilitate a strong rapport with the patient. I have also learned that a thorough history and physical is essential, as many diseases may overlap one another.

Response 2

           
Patient Information:

R.O., 31, F, African American


S.

CC (chief complaint): Vaginal Itching

HPI: RO is a very pleasant 31-year-old female who presents to clinic with concerns for persistent vaginal itching. She explains that she did a homeopathic parasite cleanse on the advice of her chiropractor. Shortly after, she developed vaginal itching and felt that her normal flora were “off”. She tried a 7-day course of Monistat which helped a little, but unfortunately triggered her migraine headaches. After the course of Monistat, symptoms returned. Today, she has itching. She is experiencing some light vaginal spotting and cramps. Sexually active with 1 male partner. Mirena IUD for pregnancy prevention placed 3/8/2018. Patient is also due for cervical cancer screening

 

Current Medications:

Adderall 20 mg oral tablet, 20 MG, 1 tab, orally, 1 time a day
Flexeril, 5 MG, orally, 3 times a day, PRN
fluoxetine 20 mg oral capsule, 40 MG, 2 CAP, orally, 1 time a day, 1 refills
Imitrex 50 mg oral tablet, 50 MG, 1 tab, orally, ONCE, PRN
Mirena 52 mg intrauteral device, 52 MG, 1 EA, intrauterine, ONCE, inserted 3-8-18, removal on or before 3-8-23 lot#TU011PR8

 

Allergies:

Zithromax
azithromycin

 

PMHx:

Anemia, iron deficiency
Chronic GERD
Generalized anxiety disorder with panic attacks
Major depressive disorder, recurrent episode, moderate degree
Migraine headache with aura
Obsessive-compulsive disorder with good or fair insight
POTS (postural orthostatic tachycardia syndrome)
Raynaud’s disease

Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx:

Glaucoma: M Grandmother. Father: History is unknown

 

Surgical Hx:

Tenotomy of foot
2007 Tonsillectomy

 

Social History

Alcohol
Current, Liquor, 1-2 times per month
Employment/School
Employed, Work/School description: Winona Health-Dialysis, RN.
Exercise
Exercise type: hiking, biking, canoeing.
Home/Environment
Lives with Significant other. Living situation: Home/Independent.
Nutrition/Health
Regular, Caffeine intake amount: tea. Diet restrictions: dairy/ red meat.
Sexual
Sexually active: Yes. Number of current partners 1. Do you think your sexual orientation as: Straight or heterosexual. What is your current gender identity? (Check all that apply) Identifies as female. Uses condoms: No. Other contraceptive use: IUD. History of sexual abuse: No.
Substance Abuse
Never, IV drug use: No. Drug use interferes with work/home: No. Ready to change: No. Household substance abuse concerns: No.
Tobacco
Never (less than 100 in lifetime) Tobacco Use (Smoking):. Smokeless Tobacco Use: Never. Tobacco Screening/Education Patient was screened for tobacco use and is a nonuser..
Electronic Cigarettes/Vaping
E-Cigarette Use: Never. Vaping Education: Patient was screened for vaping use and is a nonuser.

 

OS:

ROS: Negative except for HPI.

Physical exam:

Systolic Blood Pressure: 96 mmHg
Diastolic Blood Pressure: 62 mmHg
Pulse Rate: 63 bpm
Body Mass Index Measured: 23.06 kg/m2
Height: 183.2 cm
Weight: 77.4 kg

GENERAL: Well-developed, well-nourished. Pleasant, cooperative, in NAD.
SKIN: Normal texture, turgor, temperature. No rash noted.
HEAD: Normocephalic, atraumatic.
CARDIOVASCULAR: Regular rate and rhythm. Normal S1/S2. No murmur noted.
RESPIRATORY: Clear to auscultation to bases. No wheezes, rales or rhonchi.
ABDOMINAL: Soft, non-tender. No organomegaly. Abdominal aorta within normal limits.
MUSCULOSKELETAL: Ambulates without assistance. No pain with percussion of spinous processes, no CVA tenderness.
GENITOURINARY: External genitalia appear normal without swelling, erythema, lesions or masses. BUS negative. Speculum exam reveals healthy pink, rugated vaginal mucosa. Light, brown bleeding appreciated. Cervical os is closed, nonfriable. The strings 2.5 cm in length. No cervical motion tenderness, no adnexal masses appreciated.

 

Diagnostic Orders:

· Vaginal Wet Mount. The wet-mount test, sometimes called the wet-prep, is used for testing vaginal pH and normal flora.  This can detect inflammatory disorders of the vagina such as bacterial vaginosis.  It helps determine if there is an infection causing vaginitis that does not affect the urinary tract (Hillier et al., 2021).

· Urinalysis with reflex culture to r/o UTI.

· STI testing via PCR

· PAP Smear-the patient is due for this and has a family hx of cervical cancer, so we want to ensure cervical tissue is not contributing.

 


A

.

 

Primary Diagnosis: Vulvovaginal Candidiasis.  Vaginitis is an encompassing term for a group of inflammatory disorders of the female anatomy. Bacteria, viruses, and infections can all be responsible for causing vaginitis. Vaginal dryness d/t lack of estrogen can also be responsible for vaginitis but is less typical in those not experiencing perimenopause/menopause.  Candida involvement is more likely with the patient’s reports of itching.  She also felt symptom relief when using OTC Monistat, so this diagnosis is most likely the primary (Hillier et al., 2021).

 

DDX1: Bacterial Vaginosis.  BV is the most common of inflammatory vaginal disorders affecting women in the United States. Its symptoms include vaginal itching, discomfort, and abnormal drainage which the patient is currently experiencing (Eagan & Lipsky, 2020).

DDX 2: Trichomoniasis. Roughly 70% of trichomonas infections are asymptomatic. Common symptoms include thin malodorous and purulent vaginal discharge.  African American women experience trichomoniasis infection at a rate slightly higher than Caucasians (Workowski, 2021).  This patient is low-risk for contracting an STI, but she would like to r/o.

DDX 3: Acute simple cystitis.  Classic UTI symptoms can include cloudy or foul-smelling urine, which the patient reports she is experiencing.  She also has some mild pelvic/low back discomfort, which are also s/s of UTI.  While she has no systemic signs of infection, UTI is more prevalent in women than men d/t shorter urinary tract.  Risk factors include being sexually active (Li & Leslie, 2023).

Plan:

Fluconazole 150mg po q72h x 3 doses re: Vulvovaginal Candidiasis

Miconazole 2% cream: Apply to external genitalia two times a day as needed for up to 2 weeks Re: External Itching

The patient prefers homeopathic medicine and naturopathic choices, so we did discuss this.  She has been trying probiotics without improvement in her symptoms.

Education: There is no evidence that garlic, tea tree oil, Lactobaccilis, douching, putting yogurt in the vagina will cure or prevent candida overgrowth, or re-regulate the vaginal flora (Sobel, 2023).

 

 

 

 

 

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