response to Reena

Please respond to this discussion post by my colleague.

 

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Week 4 STI discussion

Patient Information:

SL, 24, Female, Caucasian

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S.

CC: Bleeding after sex and sore throat

HPI:Ms. Lang is a 24-year-old G0, Caucasian female presenting with complaints of postcoital bleeding and sore throat for several weeks. The patient reports postcoital bleeding for the past six weeks and a sore throat for the past three weeks. She rates her pain as a 6/10. In addition to these symptoms, she admits to a fever for the past two days, which is relieved with Tylenol. The patient reports no other acute complaints.

Current Medications:Acetaminophen (Tylenol) 325 mg PRN for fever, Pamprin OTC for menstrual cramps

Allergies:No known drug or food allergies

PMHx:No significant past medical history. Is the patient up-to-date on her immunizations?Soc & Substance Hx:Patient works as an administrative assistant. The patient is a current tobacco user, and smokes ½ pack per day since she was 14. She also drinks alcohol on the weekends and 6-8 hard liquor beverages daily. The patient uses marijuana daily. She jogs 3-4 times a week and wears seatbelts in the car and “occasionally” uses sunscreen. Does the patient text and drive? What is her support system? What is her relationship status?

Fam Hx:Non-contributary

Surgical Hx:No surgical history

Mental Hx:No history of mental illness.

Violence Hx:No concern about violence or safety.

Reproductive Hx: Onset of menses at age 13, menses every 28-32 days, lasting 4-6 days. Pt reports using 3 tampons daily while on her menstrual cycle. The patient is currently sexually active. How many sexual partners do she currently have? What is her sexual orientation? What is her sexual preference? When was her last pap smear/well woman exam? What were the results? Any history of STIs?

ROS:

  • General:No weight loss, fever, chills, weakness, or fatigue.
  • HEENT:Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose,  admits to sore throat.
  • Skin:No rash or itching.
  • Cardiovascular:No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
  • Respiratory:No shortness of breath, cough, or sputum.
  • Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain.
  • Genitourinary:No burning on urination. LMP: 12/1/2020
  • Neurological: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
  • Musculoskeletal: No muscle pain, back pain, joint pain, or stiffness.
  • Hematologic:No anemia, bleeding, or bruising.
  • Lymphatics:  Positive enlarged nodes. No history of splenectomy.
  • Psychiatric:No history of depression or anxiety.
  • Endocrinologic:No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
  • Reproductive:Not pregnant and no recent pregnancy. Positive vaginal discharge. Currently sexually active.
  • Allergies:No history of allergies.

O.

Vital Signs: BP 112/64, HR 68, RR 16, SpO2 98%, Temp 97.8. WT 118 lbs, HT 56 inches; BMI 19.04

Physical exam:

  • General:Slim, well nourished, young adult female in no acute distress.
  • HEENT:Normocephalic, atraumatic. Sclera, non-icteric, hearing intact. Anterior cervical adenopathy bilaterally. Throat erythematous
  • Cardiovascular:S1, S2 auscultated, regular rate/rhythm, no murmurs, rubs, or gallops
  • Respiratory:clear to auscultation
  • Skin:Warm, dry, and intact
  • Breast:fibrocystic changes bilaterally, no masses, dimpling, redness, or discharge, no adenopathy, and bilateral nipple piercings
  • Abdomen:flat, bowel sounds normoactive, soft, non-distended, non-tender, liver normal
  • VVBSU:Slight frothy yellow discharge by cervix, clitoral piercing noted
  • Cervix:friable, some petechia no cervical motion tenderness
  • Uterus:mid mobile, non-tender
  • Adnexa:without masses or tenderness
  • Perineum:Intact no lesions or warts
  • Rectum:Intact no bleeding or lesions
  • Extremities:Full ROM, skin clear, no edema, reflexes +1
  • Neurologic:Cranial nerves II-XII grossly intact

A.

Questions:

  1. What other information do you need?
    1. When was her last menstrual period?
    2. How much bleeding occurs after intercourse? What is the duration?
    3. How many sexual partners do she have? Is she in a monogamous relationship?
    4. Does she use protection?
    5. Has she ever had a sexually transmitted infection (STI) before? Has her partner had exposure to STIs?
    6. What other symptoms is she experiencing? How long has she been experiencing this?
    7. What kind of sex has she had recently?
    8. Do you have any vaginal itching? Burning? Urinary frequency, burning, pain?
    9. Do you have any genital sores or inside of mouth?
  2. What testing would you perform/order?
    1. Pregnancy test
    2. STI panel
    3. Pap Smear-to obtain vaginal swab for cervical cancer and STI testing
    4. Urinalysis/Urine culture
    5. Blood test-HIV, syphilis
    6. CBC-test for white count
    7. Wet Mount-testing for trichomoniasis or chlamydia
    8. NAAT-vaginal/endocervical swab/urine swab, recommended for detecting chlamydia
    9. Bimanual exam
    10. Test for pH-pH >4.5 indicative of trichomoniasis
  3. What are your initial thoughts for diagnosis?
    1. My initial thoughts for this diagnosis are a possible STI, specifically chlamydia.
    2. The patient should be treated immediately in the office and her patient should be given a prescription to treat as well.

Differential Diagnosis:

1.    Chlamydia-Chlamydia trachomatisaffects the cervix, urethra, salpinges, uterus, nasopharynx, and epididymis. It is the most commonly reported bacterial STI in the United States (Qureshi, 2018). The incubation period is 1-3 weeks for the genital tract and approximately 50% of infected males and 80% of infected females are asymptomatic. This infection can also cause pelvic inflammatory disease (PID) in women and is most common cause of epididymitis in men younger than 35 years (Qureshi, 2018). Patients will present with vaginal discharge, abnormal vaginal or postcoital bleeding, dyspareunia, fever, and slow onset of lower abdominal pain.

2.    Gonorrhea-Gonorrhea is a purulent infection that can be spread through sexual contact, mucous membrane, or during childbirth (Wong, 2018). Patient present with mucopurulent or purulent vaginal, urethral, or cervical discharge, vaginal bleeding, cervical friability, cervical motion tenderness during bimanual pelvic examination, fullness or tenderness of the adnexa, lower abdominal pain/tenderness, possible low back pain, and fever (Wong, 2018).

3.    Pelvic Inflammatory Disease (PID)-PID is an infectious and inflammatory disorder of the upper female genital tract (Tough, 2019). Risk factors include menstruating females under 25, multiple sex partners, does not use contraception, and resides in a high prevalent STD area (Tough, 2019). Patient will present pelvic or lower abdominal pain, cervical motion tenderness, uterine tenderness, or adnexal tenderness, fever, and elevated erythrocyte sedimentation rate (ESR).

P.

            To properly treat patients diagnosed with chlamydia, a single dose, in office treatment is used to improve compliance and confidentiality (Qureshi, 2018). The patient will receive Azithromycin 1 gram or doxycycline 100 mg twice daily for 7 days. The partner(s) should also be tested and treated. The patient should be educated about the most effective way to avoid infection, such as practicing safe sex. The patient should also be counseled on birth control options to avoid unwanted pregnancy. ACOG recommends expedited partner therapy unless contraindicated such as suspected abuse or compromised patient safety (Qureshi, 2018). Test of cure is not necessary unless the patient believes they have been reinfected. However, is it a recommendation the patient follow up in 3-4 weeks to repeat examination and test for cure if the patient has recurrent or persistent cases, which can lead to infertility (Qureshi, 2018).

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