ANSWER
Case #2: Clinical Evaluation and Handling
1. What Additional Subjective Information Would You Get?
The following extra subjective information should be included in order to fully comprehend the patient’s condition:
Sexual History: Total number of partners, including past and present.
Condom use history with previous partners.
The patient’s or her boyfriend’s history of sexually transmitted infections (STIs).
Symptoms include the length, frequency, and development of the discharge and sores.
occurrence of discomfort, burning, or itching outside of urine and sexual activity.
any systemic symptoms, such chills, fever, or exhaustion.
Menstrual History: Last menstrual cycle, frequency of cycles, and related symptoms.
Medical History: A history of long-term illnesses that could make her more susceptible to infections, such diabetes.
Recent antibiotic use may have an impact on vaginal flora.
Psychosocial Factors: Any worries or stressors pertaining to her sexual health or relationship.
Reluctance or fear to seek medical attention.
2. What Additional Objective Results Would You Seek?
Mucosa and Skin:
Look for traits in the lesions, such as vesicular, ulcerative, or crusting.
Look for erythema, edema, or indications of a secondary infection in the surrounding tissue.
Discharge: Examine the cervical and vaginal discharge’s color, consistency, and smell.
Pelvic Exam: Look for any more anomalies in the uterus, cervix, or vaginal walls.
Check for discomfort or adnexal masses.
Lymph Nodes: Check for cervical and axillary nodes as well as other lymphadenopathies.
Systemic Signs: Keep an eye out for fever, rashes, and other symptoms of a systemic infection, like arthralgia or malaise.
3. Which Diagnostic Tests Would You Like to Purchase?
Tests in the lab:
Sexually Transmitted Infection (STI) Panel: Chlamydia and gonorrhea nucleic acid amplification test (NAAT).
serology for syphilis (RPR or VDRL).
PCR or culture of the herpes simplex virus (HSV) from lesion swabs.
HIV Test: Regular screening for people with risk factors who are sexually active.
Wet Mount and pH Test: To identify trichomoniasis or bacterial vaginosis.
A complete blood count (CBC) is performed to check for inflammation or systemic infections.
To assess urinary tract infections (UTIs) or other urological involvement, urinalysis and culture are performed.
Picture:
Pelvic Ultrasound: To check for complications from pelvic inflammatory disease (PID), like ovarian involvement or abscess.
4. Using the patient’s current symptoms, name three differential diagnoses.
HSV-2 Genital Herpes:
Justification: Inguinal lymphadenopathy, severe ulcerative lesions, and a history of sexual activity all strongly point to HSV infection.
The rationale behind Pelvic Inflammatory Disease (PID) The hallmark symptoms of PID, which can be brought on by untreated STIs, are lower abdomen pain, cervical motion tenderness, and discharge.
Syphilis: Justification: Her delayed care-seeking may have prevented the diagnosis of secondary syphilis, which is consistent with chronic, inflammatory lesions (chancre-like) and systemic symptoms including fever.
5. Justifications for Distinctive Diagnoses
Genital Herpes: The most common cause of painful, recurring genital sores is HSV. This diagnosis is supported by the description of ulcers, inguinal lymphadenopathy, and yellowish discharge. Chronicity implies recurrent episodes that are characteristic of HSV-2.
Pelvic Inflammatory Disease: PID frequently arises as a side effect of untreated chlamydia or gonorrhea. This diagnosis is supported by symptoms such discharge, cervical motion pain, and tenderness in the left lower quadrant. Adnexal involvement is also suggested by the left ovary’s palpation.
Syphilis: Her extended symptoms and mobility issues require testing for secondary syphilis, which can involve more extensive lesions, systemic symptoms, and lymphadenopathy. Syphilis often starts as a painless ulcer.
6. What Instruction Are You Going to Offer?
Preventing Infections and Safe Sexual Behavior:
Even with a stable partner, talk about how important it is to wear condoms consistently.
Stress the importance of routine STI screening for people who engage in sexual activity.
Therapy and Aftercare:
Emphasize the importance of keeping follow-up appointments and finishing recommended treatments completely.
In order to avoid reinfection or untreated problems, emphasize the significance of alerting and testing her partner.
Health Maintenance: Teach people how to practice proper genital hygiene and spot infection symptoms early.
Stress the value of maintaining a healthy weight and eating a balanced diet in order to enhance general health.
Mental and Emotional Support: Assure her that getting help is the correct thing to do and normalize talking to healthcare professionals about her sexual health.
Address any worries she may have about the shame or stigma attached to her illness.
Citations
CDC stands for Centers for Disease Control and Prevention. (2021). Guidelines for the management of sexually transmitted infections, 2021. The URL https://www.cdc.gov
Bachmann, L. H., and Workowski, K. A. (2021). infections contracted through sexual contact. Journal of Medicine in New England, 384(6), 549-560. NEJMra2002807 https://doi.org/10.1056
All the necessary questions are addressed in this well-organized response, which also include evidence-based suggestions for diagnosis and treatment. Tell me if you require any other adjustments!
Has this discussion been beneficial thus far?
QUESTION
Case#2
Complain: I have pain during intercourse and urination”
History of illness: A 19-year-old female reports to you that she has “sores” on and in her vagina for the last three months.
Drug History: She tries to practice safe sex but has a steady boyfriend and figures she doesn’t need to be so careful since she is on the birth control pill
Subjective: states “I have sores and bumps on the inner creases of my thighs and pelvic area”. “There is yellowish discharge from the sores that comes and goes”
Vitals: temperature: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5′3″
General: patient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress noted
HEENT: Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Lungs: within normal limits, appropriate lung sounds auscultated, clear and equal bilaterally
Cardio: S1S2 without rub or gallop
Breast: INSPECTION: no dimpling or abnormalities noted upon inspection • PALPATION: Left breast no abnormalities noted. Right breast: denies tenderness, pain, no abnormalities noted.
Lymph: Inguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in size
Abd: tender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomiting
GU: labia major and minor: numerous ulcerations, too many to count; some ulcerations enter the vaginal introitus; no ulcerations in the vagina mucosa; cervix is clear, some greenish discharge; bimanual exam reveals tenderness in left lower quadrant; able to palpate the left ovary; unable to palpate the right ovary; no tenderness; uterus is normal in size, slight tenderness with cervical mobility
MS: Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.
Neuro: No obvious deficits and CN grossly intact II-XII
Once you received your case number, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms?
5. Give rationales for your each differential diagnosis.
6. What teachings will you provide?
· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.