Vaginal discharge is a common complaint of sexually active young women and is frequently a reason to visit a clinic. In this case, we talk about Lisa, a 19-year-old female, with abnormal vaginal discharge one week after unprotected intercourse with a new partner. As her healthcare provider, it is essential to adopt a systematic approach by using the SOAP format (Subjective, Objective, Assessment, and Plan) to come up with a timely and efficient diagnosis and treatment plan.
Subjective: Key Questions and Clinical History
Lisa complains of abnormal vaginal discharge for one week after unprotected vaginal intercourse. Her last menstrual period was two weeks ago and her pregnancy test is negative. In order to collect a full picture, several key questions should be asked. For the history of present illness (HPI), you should ask about the color, odor, consistency and quantity of the discharge. Is there any accompanying itching, burning, pain in the pelvis, urinary symptoms, or fever? Ask her if she had similar symptoms before.
Further, explore Lisa’s sexual history. Is she promiscuous lately? Was this her first sexual encounter with the new partner? Did he reveal any known history of STIs? Has she ever been positive for any STI earlier? Inquire about use of contraceptives, condoms or other barrier methods and when and how often they have sex.
Her medical history should include a history of any previous gynecological problems such as recurrent infections, pelvic inflammatory disease (PID), or abnormal pap smears. It is also essential to discuss allergies, recent antibiotic use, current meds, and her vaccination history, particularly for HPV and hepatitis B.
In the social history, find out if Lisa smokes, drinks alcohol or uses recreational drugs. Knowing her lifestyle can help to identify any immunocompromising conditions or behaviors that may increase the risk of infection. You should also evaluate her psychosocial background, as well as history of trauma and sexual coercion.
Objective: Testing and Diagnostic Evaluation
The vital signs should be the first step in physical exam to rule out systemic infection. A pelvic exam is necessary to evaluate the appearance of the vaginal discharge, cervical motion tenderness, and presence of adnexal masses or tenderness.
For diagnosis and treatment, various point-of-care tests (POCT) should be ordered. First, a urine NAAT (nucleic acid amplification test) for Chlamydia trachomatis and Neisseria gonorrhoeae should be done because of their high prevalence in young sexually active females and the possible complication like PID and infertility. Wet mount (saline microscopy) and KOH prep should be used to evaluate for Trichomonas vaginalis, Candida albicans and bacterial vaginosis (BV). A vaginal pH test is also useful. BV and trichomoniasis usually increase the pH above 4.5, while candidiasis does not.
Other POCTs are rapid HIV test that is important for early detection and counseling and RPR/VDRL to screen for syphilis. These tests are routine based on Lisa’s unprotected sex and new partner. It is also wise to carry out a Herpes Simplex Virus (HSV) swab if any ulcers or vesicles are found.
Assessment and Plan: Diagnosis, Treatment, and Follow-up
The most likely diagnosis for Lisa is Chlamydia trachomatis cervicitis, a common sexually transmitted infection (STI) in her demographic. Symptoms of abnormal discharge following unprotected sex with a new partner support this diagnosis. Alternative or co-infections to consider include gonorrhea, trichomoniasis, bacterial vaginosis, or vulvovaginal candidiasis.
If Lisa’s chlamydia test is positive, the current CDC guidelines suggest Doxycycline 100 mg orally twice daily for 7 days as a first-line treatment. Alternatively, Azithromycin 1 g orally in a single dose can be used in some cases like pregnancy or compliance issues. It is important to counsel her about side effects, such as gastrointestinal upset, photosensitivity (doxycycline), or nausea (azithromycin). Emphasize on following the full course to ensure efficacy and avoid resistance.
Two forms of intercourse with the highest risk of HIV transmission are receptive anal intercourse and receptive vaginal intercourse, and the former has the highest per-act risk. Women are more at risk of contracting HIV during heterosexual intercourse as a result of biological factors- the vaginal mucosa is more susceptible to microtears and has a greater surface area for viral transfer. In addition, semen contains a high concentration of HIV as compared to vaginal fluids hence increasing the risk for male to female transmission.
Lisa should be counseled to abstain from sexual intercourse until her symptoms are improved and treatment is over. A test-of-cure is not normally indicated for chlamydia but retesting in 3 months is recommended because of high rates of reinfection. Expedited partner therapy (EPT) should be provided – Lisa’s partner needs to be tested and treated to avoid reinfection. Advise on safe sex practices, i.e., regular condom use, and educate on HIV prevention, i.e., PrEP (pre-exposure prophylaxis) if at continued risk.
If other infections are diagnosed (e.g., BV or trichomoniasis), treatment should be individualized. For trichomoniasis, metronidazole 2 g orally single dose is recommended. Tell her to abstain from alcohol for 24-72 hours because of disulfiram-like reaction. For BV metronidazole 500 mg orally twice daily for 7 days is the first line treatment.
To conclude, Lisa’s case requires detailed history of sexual and medical life, adequate diagnostic test, and evidence-based treatment. As the healthcare provider, you are also responsible for education, prevention counseling and follow up care to ensure resolution and minimize recurrence. Prompt intervention does not only enhance Lisa’s reproductive health but also helps to promote public health by reducing the spread of STIs.
Related Nursing Task
Lisa is a 19-year-old female who presents to the clinic c/o abnormal vaginal discharge for one week after having unprotected vaginal intercourse with a new male partner she has been dating for a couple of weeks. Lisa’s pregnancy test is negative and her LMP was 2 weeks ago. As her health care provider, you will need to perform testing to determine if Lisa has contracted a sexually transmitted infection or other vaginal infection.
Write a brief SOAP note regarding this patient. Make sure to include your answers
to these questions in your SOAP note.
1. Subjective:
a. What other relevant questions should you ask regarding the HPI?
b. What other medical history questions should you ask?
c. What other social history questions should you ask?
2. Objective:
a. Explain what POCT will you order and perform, and discuss your
rationale for ordering and performing each test.
3. Assessment/ Diagnosis:
a. What would be an appropriate diagnosis for her? Why?
b. Any other diagnosis or differential diagnosis you would like to add?
4. Plan:
Name 2 types of intercourse are at the highest risk for contracting HIV
Why are women more susceptible to HIV in a male to female relationship (versus a male contracting it from a female)?
a. What will you prescribe for this patient? Why? (assume one of your lab test results is positive), Explain what medications and treatments you would recommend
b. Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s), partner notification, and follow-up plan of care.
Order an Essay Now & Get These Features For Free:
Turnitin Report
Formatting
Title Page
Citation
Outline
