Response 1

Patient Information:

S.L., 24 y/o, Caucasian Female

S.

CC: Postcoital bleeding, sore throat, fever (see questions below)

HPI: A 24 year old Caucasian female presented to the clinic with complaints of postcoital bleeding for the past six week and a sore throat for the past three weeks.  She stated that she had a fever for a day or two. The bleeding occurs after sex. The complaints are that the throat is sore and red. Symptoms are relieved by Tylenol. Symptoms started about six weeks ago.

Current Medications: No prescription medications.

Over-the-counter medications: Pamprin as needed.

Allergies:  No known drug allergies.

PMHx:

No medical history—I would ask who her primary physician was?

· I would ask about immunizations here such COVID, HBV, Hepatitis, etc.

· I would ask when her last Pap smear was? When was her last pelvic exam?

Soc & Substance Hx:

Cigarette smoking 1/2pack daily since age 14. ETOH only on weekends, 6-8 hard liquor daily. Marijuana smoking. She works full-time as an administrative assistant and states she loves her job.  She jogs 3-4 times a week, wears seatbelts when in the car and occasionally uses sunscreen.

Fam Hx: Non-contributary

Surgical Hx:  No surgical history

Mental Hx:   not discussed.

Violence Hx:  Would ask questions about if she feels safe and about safety in her relationship.  (See below)

Reproductive Hx: GYN history—onset of menses at age 13, menses every 28-32 days, lasting 4-6days and she uses 3 tampons on average daily.

ROS:

GENERAL: sore throat, fever in the past relieved by Tylenol.

HEENT: Throat:  sore throat for past 3 weeks.

CARDIOVASCULAR: Would ask her if she has had any chest pain, chest discomfort or palpitations? This would be done to rule out any cardiac symptoms.

RESPIRATORY:  Would ask her if she has had any shortness of breath, cough, congestion? This would be done to rule out any respiratory symptoms.

GASTROINTESTINAL: Would ask her if she has had any abdominal pain, nausea, vomiting, diarrhea, constipation? This would be done to rule out any gastrointestinal symptoms that could indicate a virus.

GU: Would ask questions about urination? Leakage? Dribbling? Incontinence? Burning on urination? Pain on urination? Foul odor on urination? Any problems urinating?

NEUROLOGICAL: Would ask her if she has had any headache, dizziness, muscle cramps, weakness? This would be done to rule out any neurological symptoms that she could be having and did not realize.

MUSCULOSKELETAL: Would ask her if she has had any muscle pain, weakness, muscle spasms? This would be done to rule out any symptoms that could be affecting the muscular structure.

HEMATOLOGIC: Would ask her if she is having any bruising, free bleeding? This would be done to rule out any bleeding problems or clotting issues since she is already stating she is having postcoital bleeding.

LYMPHATICS: Would ask her if she is having any enlarged lymph nodes, headaches? This would be done to rule out any lymphatic symptoms issues that she might not state.

PSYCHIATRIC: Would ask her if she is having any problems with anxiety or depression? This would be done to determine if she is experiencing any signs of a mental condition.

ENDOCRINOLOGIC: Would ask her if she is experiencing hair loss, heat/cold sensitivities? This would be done to determine to rule out if she is having any thyroid issues.

GENITOURINARY/REPRODUCTIVE: GYN history—onset of menses at age 13, menses every 28-32 days, lasting 4-6days and she uses 3 tampons on average daily. She has some cramping during her menses.  Postcoital bleeding for past 6weeks.

ALLERGIES: No c/o allergies                                                                                       

O.

Vital Signs:  Temp97.8 HR:68, BP: 112/64.  Height:66 inches, Weight:118 lbs. (no change from last year), BMI:19.04

Physical exam:

HEENT: within normal limits except some anterior cervical adenopathy bilaterally, and throat appears reddened.

LUNGS: clear to auscultation.

CV: regular sinus rhythms without murmur or gallop.

BREAST: fibrocystic changes bilaterally, no masses, dimpling, redness, or discharge, no adenopathy, and bilateral nipple piercings.

Abdomen: soft, non-tender, liver normal.

VVBSU: within normal limits, 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: within normal limits.

RECTUM: within normal limits.                

EXTREMITIES: full range of motion, skin clear, no edema, reflexes 1+.

NEUROLOGICAL: CN II-12 grossly intact.

 

Diagnostic results:

            Nucleic acid amplification test (NAAT)- This testing is specifically sensitive to the bacteria that causes chlamydia and gonorrhea. NAAT testing has been the gold standard of screening because of its sensitivity and specificity are high for  Chlamydia trachomatis and  Neisseria gonorrhoeae (Davidson et al. 2021Because gonorrhea and chlamydia symptoms mimic each other, this test is sensitive enough to differentiate between the two STI.

Complete STI panel—This is used to detect an signs or tracts of any sexually transmitted infection.  Because the NAAT is most sensitive to chlamydia and gonorrhea, it very well may miss other STIs.  It is not uncommon for a person to have more than one STI at a time.  This panel will detect for not only gonorrhea and chlamydia but also herpes, syphilis, HIV1 and HIV2 as well as Hepatitis B and Hepatitis C.

            Pregnancy test—This is done to rule out the possibly of pregnancy.  If it is determined a patient is pregnant, then the treatment plan must be adapted. If it is determined a patient is pregnant, gonorrhea and chlamydia can affect the patient as well as the fetus, so treatment plan becomes more urgent.

            Urinalysis w/culture and sensitivity if indicated—This is used to evaluate the urine for the presences of bacteria, nitrites or leukocytes.  If found, these can cause pain on urination, fever leading to a diagnosis of UTI.

            KOH Whiff test—This test is done to rule out bacterial vaginosis. The technician will perform the test and it is considered positive if a strong fishy odor is detected.

            Throat swab—This should be done to rule out strep throat.  The patient has a sore, red throat and has been running a fever.  These could be symptoms of strep throat. 

Primary Diagnosis:

  Gonorrhea—A54.9 This is one of the most common STIs among sexually active men and women.  The most common symptom of this infection is vaginal discharge, pain on urination, fever, and postcoital bleeding. Sore throat is common is a patient is having oral contact with an infected person (AAFP,2023).  Our patient is having three of the five symptoms, so this would be considered the primary diagnosis.

Chlamydia—A74.9 – This is one of the most common STIs among sexually active men and women.  The most common symptoms of this infection are pain on urination, itching of the vagina, postcoital bleeding and lower abdominal pain (AAFP,2023). Because our patient only has one of the symptoms with diagnosis could be ruled out but would wait for diagnostic testing before ruling out.

Bacterial Vaginosis---N77.1 This is a common bacterial infection among sexually active women.  The most common symptom of this infection is white/gray vaginal discharge, pain/itching of the vagina, strong fishy vagina odor, postcoital bleeding. Because our patient only has one of the symptoms, this diagnosis could be ruled out but would wait for diagnostic testing before ruling out.

Treatment:

Doxycycline 100mg orally twice a day for 7days. This is the recommended treatment for Chlamydia. Pt. should observe for side effects such as nausea, vomiting, diarrhea, poor appetite, headache, skin rash. Pt. must be educated to complete the entire prescription. She will be educated to any supplements or antacids, two hours after taking mediation. She should take it with a full glass of water.

Ceftriaxone 500mg IM for one dose. This is the recommended treatment for Gonorrhea.   Pt should observe for side effects such as itching, skin rash, swelling of hands/face, or trouble swallowing. Pt. to wait 30mins after dosing to ensure no adverse reactions noted.

These are treatments for both gonorrhea and chlamydia.  Because the NAAT laboratory test will take a little while to come back, I would treat for until I get the results.  Once the results are back, I will reevaluate to see if a treatment regimen is needed.

Patient Education:

Patient educated that a follow up is needed in three months or if symptoms do not resolve.  CDC recommends that the patient be rescreened for gonorrhea and chlamydia three months after treatment to determine if the infection has resolved (CDC,2021).

Will educate on the treatment plan.  Review the antibiotic needed and the side effects to be observing for during the treatment course.  She is encouraged to drink plenty of water and avoid dairy products. Pt. educated that is side effects occur, she is to notify the provider promptly.        

Pt. educated on the practice of safe sex and how to prevent STIs.

Pt. counseled that she needs to abstain from sexual activity until she has completed the treatment plan and the symptoms for resolved.

Pt. counseled that her partner/partners also need to be treated for STIs as well.

Questions:

The following are additional questions I would ask the patient:

--Before we start, may I ask how you would like to be addressed?

--What is your sexual orientation? When was the last time you had sex?  How many sexual partners do you have? What is your preferred sexual act such as oral, anal, vaginal? Do you use protection during sex such as condoms? Have any of your partners had any problems such as discharge, pain, itching or fever? Do you have any pain during intercourse? Have noticed any sores or lesions on your vagina?

--When did you notice your current symptoms? Are you having a discharge? If so, color of discharge? Are you having any itching? How high did your fever get? Are you having any burning on urination? Do you have pain during sex?

--Have you ever had a sexually transmitted infection? What was it? When did you have it? What type of treatment did you have?

--Are you in any pain? If so, where? How would you rate it on a scale of 1-10 with 10 being the worse?

--When was your last pap smear? What was the results of the pap smear? If abnormal, what was the problem and what was the treatment?

--Do you have any religious or cultural issues or needs that we need to be aware of?

--Do you feel safe in your relationship and your home? Have you ever been forced or coerced into having sex or doing sexual acts? Are you afraid of your partner? Do you feel threatened or forced? Are you being physically, mentally, or sexually abused?

--Have you had any feelings of depression or anxiety? Do you find sexual pleasurable?

Reflections

     This was a very interesting decision.  I have had a lot of dealing with sexually transmitted infections through the emergency room, but this is a whole new experience.  You have dealing directly with the women and the infection.  Most of the diagnostic tests take a little time for them to result out, so going a head a treating the patient is a must. Any of the three diagnoses mentioned, could result in adverse dangerous effects on the patient. So, while waiting for the results of the test, we treat.

RESPONSE 2

JM 47F, Hispanic

S.

CC (chief complaint): Lower abdominal cramping and urinary leakage for the past day

HPI: JM is a 47 year old Hispanic female who is G5P5006 who presents to the office complaining of lower abdominal cramping and urinary leakage for the past day. She states the abdominal cramping in the subrapubic area started several hours ago. She states it is sharp in nature, intermittent in frequency but getting more frequent and painful. She tried Motrin but states it did not help. She had a UTI years ago and she states this feels similar to that with the exception of the incontinence. She is complaining of feeling more tired for the past several months. She relates that she stopped getting her period about 8 to 12 months ago and she states that menopause was easy. She denies any medical or surgical history. She has no known drug allergies and takes no medications. She denies any alcohol, tobacco or recreational drug use. She relates that she has had some constipation and increased gas for the past several months. She was using natural family planning for contraception prior to her stopping her period. She denies any other urinary symptoms.

Current Medications: Motrin PO PRN

Allergies:  NKDA, No seasonal or environmental allergies.

PMHx: UTI in the remote past. Denies any other significant medical history. Soc & Substance Hx: Denies alcohol, tobacco or recreational drug use.

Fam Hx: Noncontributory

Surgical Hx:  None

Mental Hx:  Denies

Violence Hx:  Denies

Reproductive Hx: Postmenopausal. 5 Pregnancies, 5 fullterm births, 0 preterm births, 0 abortions and 6 living children.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows:  General:  Head:  EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete 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, or 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. Complains of suprapubic abdominal pain with some constipation and increased gas for the past several months.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Complains of urinary incontinence started yesterday.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No 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.

GENITOURINARY/REPRODUCTIVE: Urinary incontinence. Post-menopausal. G5P5006.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam:

HEENT: WNL

Neck: Grossly normal. No cervical tenderness or rigidity

Lungs/CV: Chest CTA bilaterally with normal respiration

Breast: Normal breast exam. No nipple tenderness or discharge

Abdomen: Obese adult female. Suprapubic tenderness

VVBSU: WNL

Cervix: Firm and smooth

Uterus: difficult to access due to body habitus. Feels normal.

Adnexa: Not palpable due to body habitus

MS: No trauma or deformities

Neuro: CN II-XII grossly intact

Skin: No bruises or rashes.

Diagnostic Tests: UA with C/S if Ind., STI panel, POC urine HCG.If positive a Quant hcg will be ordered and the patient will be sent to the hospital with possible active labor. If her Hcg is negative then a Pap test, wet mount, CBC, and CMP

Additional questions to ask:

· What color is the vaginal spotting? The color of the vaginal discharge can indicate what it is. For example, bright red blood can indicate active bleeding that may be from a period, cervical infection, cervical polyp or cancer. Clear discharge can indicate pregnancy or ovulation. White discharge can indicate a yeast infection. Gray discharge can indicate bacterial vaginosis. A yellow-green discharge can indicate a STI and a pink discharge can indicate cervical bleeding, vaginal irritation or implantation bleeding (Cleveland Clinic, 2022).

· Does the abdominal pain radiate anywhere such as your flank area? With the abdominal pain and proteinuria with a slightly elevated temperature, I’d be concerned about a pyelonephritis. Pyleonephritis or kidney infection can be caused as a complication of a UTI (Belyayeva & Jeong, 2022).

· Have you had preeclampsia during any of your previous pregnancies? Because the patient could possibly be pregnant and spilling protein in her urine, I’d be very concerned about preeclampsia. The risk factors include obesity, multiple pregnancies, being older than 35 and history of DM, hypertension or kidney disease (National Library of Medicine, n.d.).

· Any history of kidney disease in your family? Spilling protein in urine can be caused by many things, one which is kidney disease (Cravedi & Remuzzi, 2013).

A .

Primary Diagnoses: UTI. All the symptoms she’s having with a previous history of a UTI with similar symptoms points to a UTI.

Differential Diagnosis:

· Pregnancy with active labor – This is an obvious “must not miss” differential. Since it’s been around 9 months (she states 8 to 12 months) since her last period and she’s perimenopausal, it’s very well possible she’s pregnant and starting to go into labor. Since she’s been using natural family planning and not any contraceptives, its possible she’s been pregnant the past 8 to 10 months and the suprapubic pain and discharge are signs of labor.

· Cystitis – Acute cystitis often includes dysuria, frequency, urgency, suprapubic pain and hematuria (Li & Leslie, 2023).

· Vaginitis – This is an inflammation of the vagina that can cause itching, burning, odor and discharge (ACOG, n.d.). This is ruled out because she is not complaining of most of these symptoms.

· STI – STIs can cause many of the symptoms that our patient has. A STI panel will be performed to rule out such things as chlamydia and gonorrhea.

· PID – Pelvic Inflammatory disease can be caused by untreated STIs, and having multiple sex partners among other factors (CDC, n.d.). It can cause lower abdominal pain, fever, discharge, bleeding and dysuria (CDC, n.d.).

· Kidney Disease – As stated earlier, spilling protein can be a symptom of kidney injury. A CMP can determine if there is an acute kidney injury.

 

P.

The first thing is to collect a UA and send it to laboratory to do a urine culture. The second thing is to check her for pregnancy. Because of her age, it’s unlikely she’s pregnant but it’s a must not miss diagnosis. It’s very possible she’s pregnant and starting to go into labor because she last had her period at least 8 months earlier and she’s not used contraceptives, only relying on natural family planning. If she is pregnant, she needs to be sent to the ER to be admitted to the OB unit of the hospital for possible active labor. If her pregnancy test is negative, then she will be worked up for a pap smear to rule out cancer and a wet mount to rule out STIs. If these are negative she will be sent home with an antibiotic for an uncomplicated UTI.

Rx:

Bactrim DS 1 tab PO BID x 3 days. Sig: 6 tabs. No refills.