Patient Information
Initials: AM Age:26 Sex: F Race: Hispanic
Subjective Data
CC: “watery fish-smelling vaginal discharge”
HPI: A 26-year-old Hispanic female presents with a complaint of watery fish-smelling vaginal discharge. The symptoms started about a month ago, and attempts to get rid of the odour have not been successful. AM tried taking showers frequently, but no relief was noticed. She is sexually active and has one partner of the male gender.
Location: vagina
Onset: 30 days ago
Character: watery discharge with a very unpleasant odour
Associated signs and symptoms: occasional skin irritation in the vagina
Timing: all day round
Exacerbating/ relieving factors: when hydrocortisone topical (ointment) is applied, the itching becomes less severe, but the smell still does not disappear
Severity: 9/10 pain scale
Current Medications: hydrocortisone topical (ointment), several times a day for the past two weeks
Allergies: peanuts (angioedema); pollen (allergic rhinitis); penicillin (anaphylaxis)
PMHx
Pneumonia – treated five years ago
Chlamydia – treated two years ago
Vaccinations – MMR, HepB, DTaP, Var, PCV, IPV, RV, HPV, PCV13
Last tetanus vaccination – two years ago
Soc Hx: AM is a hotel manager, and she spends much time at work. In her free time, the patient enjoys doing sports and going places. AM is not married, but she has been in a serious relationship for the past three years. The patients used to smoke when she was a teen, but she quit nine years ago. AM can occasionally have a few glasses of wine, but she is very self-cautious and always controls the consumption. The patient has three years of driving experience; she always fastens her seat-belt and makes her passengers do the same. AM’s apartment is situated in a clean district, not far from her parents’ home. The family is friendly, and AM can always rely on them. Her mother even accompanied her to the appointment in case the patient would not be able to drive back home.
Fam Hx: AM’s maternal grandmother died of ovary cancer. AM’s mother has been treated for cervical dysplasia, and she suffers from menstrual disorders.
ROS
GENERAL: AM has lost one pound over the past month; she does not experience fatigue or any health changes.
HEENT: Eyes: normal vision. Ears, Nose, Throat: normal hearing, no throat pain, no abnormal nose discharge.
SKIN: no itching or rash.
CARDIOVASCULAR: no pain in chest; no oedema or palpitations.
GASTROINTESTINAL: loss of appetite; no vomiting, or diarrhoea, nausea, or anorexia. No abdominal pain or blood.
GENITOURINARY: Last menstrual period: 1/20/2019. No pregnancies, abortions, or miscarriages.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCTINOLOGIC: No polydipsia or polyuria. No heat or cold intolerance.
Objective Data
Physical exam
Vital signs: Height 5’7”; Weight 134 lbs; BP 125/65; T 97 F°; P 73 bpm.
General: The patient appears neat, clean, and well-nourished. She answers all questions easily and seems alert.
HEENT: Head normocephalic; eyes clear, no difficulty focusing; ears clean; no pain in the neck; throat clear.
Genital: External genitalia pink, no oedema, cervix intact, thin foul yellowish-greyish discharge in the vaginal canal.
Skin: warm, soft, dry to touch.
Diagnostic results: obtaining secretions from posterior fornix with the help of a Q-tip (a wet mount test); microscopic examination to check the pH of the vaginal secretions; a whiff test to assess the odour.
Assessment
Differential Diagnoses
- Bacterial vaginosis (BV) is the most typical reason for vaginal discharge in women at reproductive age. This condition can cause several negative reproductive health outcomes, the severest one being the acquisition of HIV-1 (Mitchell & Marrazzo, 2014). BV is characterised by the loss of normal lactobacilli and vaginal colonisation with anaerobic bacterial species. The clinical presentation of BV does not necessarily include swelling or redness, but it frequently includes odorous discharge (Mitchell & Marrazzo, 2014). A wet mount test is the most reliable way of diagnosing BV. This diagnosis is the most likely for the patient, taking into consideration her past history of chlamydia.
- Chlamydia trachomatis is the leading cause of bacterial sexually transmitted infections (STIs) (Yeung et al., 2017). Chlamydiae are gram-negative obligate intracellular bacteria which can lead to genital infections, including infertility and pelvic inflammatory disease. The cervix is one of the organs most frequently affected by chlamydia. A swab test and a urine test can be employed to diagnose this STI. The patient has past history of chlamydia, and she is at reproductive age, which makes it necessary to check this diagnosis.
- Urinary tract infections are often associated with gynaecologic health issues (Gillmor-Kahn, 2017; Sheng & Miller, 2017). When a woman’s organism has a susceptible host and an active pathogen, the likelihood of such an infection is increased (Gillmor-Kahn, 2017). A urine test or cystoscopy can be used for diagnosis. Problems with urinary tract may cause serious physical, social, or emotional discomfort (Tharpe, Farley, & Jordan, 2017). Thus, it is crucial to diagnose the infection as soon as possible and start treatment immediately.
Plan
Treatment Plan
If the diagnosis of bacterial vaginosis is confirmed by the wet mount test, it is necessary to start treatment. The most typical treatment plan includes the following options:
- 500 mg metronidazole two times a day;
- 2% vaginal clindamycin cream once a day for a week;
- oral clindamycin 300 mg two times a day for a week;
- metronidazole 0.75% vaginal gel once a day for five days;
- “the stat regimens of 2 g of metronidazole or tinidazole in a single dose” (Donders, Zodzika, & Rezeberga, 2014, p. 647).
Alternative treatment includes probiotic supplementation, which has been proven to prevent BV recurrence (Parma, Stella Vanni, Bertini, & Candiani, 2014).
Health Promotion
During treatment, the patient should abstain from consuming alcoholic drinks. Also, she should avoid intercourse in order to eliminate the risk of passing the infection to her partner.
Disease Prevention
To prevent the recurrence of BV, the patient should use condoms during intercourse and avoid douching too frequently. Also, she should not use daily pads since they can irritate skin.
Reflection
The experience has increased my knowledge about STIs, as well as the difficulty of their diagnosis and treatment. In particular, I realised how similar symptoms of some illnesses could be. Without the correct diagnosis, a healthcare provider risks selecting wrong medicines, which can lead to the complication of the patient’s condition. Therefore, the most important lesson from the experience was acknowledging the need for a very thorough examination of patients with genitourinary system problems. I understood that my patient’s health and future reproductive life depended on the correctness of the diagnosis. However, the responsibility did not affect me in a negative way: I did not feel anxious and instead, decided to do everything possible to obtain the necessary test results.
In the future, I would probably approach a similar patient evaluation a little differently. In particular, I would pay more attention to the lymphatic system during examination because it is closely related to women’s reproductive system. Also, I would recommend the patient not to seek an appointment after a month since she first noticed the symptoms. I would assert the need for regular examinations and invite the patient to pass the text for BV in two or three weeks. In general, I was satisfied with the results that I managed to obtain during examination and tests.
References
Donders, G. G. G., Zodzika, J., & Rezeberga, D. (2014). Treatment of bacterial vaginosis: What we have and what we miss. Expert Opinion of Pharmacotherapy, 15(5), 645-657.
Gillmor-Kahn, M. (2017). Urinary tract infections. In K. D. Schuilig & F. E. Likis (Eds.), Women’s gynecologic health (3rd ed.) (pp. 513-524). Burlington, MA: Jones & Bartlett Learning.
Mitchell, C., & Marrazzo, J. (2014). Bacterial vaginosis and the cervicovascular immune response. American Journal of Reproductive Immunology, 71(6), 555-563.
Parma, M., Stella Vanni, V., Bertini, M., & Candiani, M. (2014). Probiotics in the prevention of recurrences of bacterial vaginosis. Alternative Therapies in Health and Medicine, 20(1), 52-57.
Sheng, Y., & Miller, J. M. (2017). Urinary inconsistence. In K. D. Schuilig & F. E. Likis (Eds.), Women’s gynecologic health (3rd ed.) (pp. 525-548). Burlington, MA: Jones & Bartlett Learning.
Tharpe, N. L., Farley, C. L., & Jordan, R. G. (2017). Clinical practice guidelines for midwifery & women’s health (5th ed.). Burlington, MA: Jones & Bartlett Learning.
Yeung, A. T. Y., Hale, C., Lee, A. H., Gill, E. E., Bushell, W., Parry-Smith, D.,… Hancock, R. E. W. (2017). Exploiting induced pluripotent stem cell-derived macrophages to unravel host factors influencing chlamydia trachomatis pathogenesis. Nature Communications, 8, 15013.