Ana Claudia

SUBJECTIVE DATA: 
(Coudray & Madhivanan, 2020)

S: The patient is a 35-year-old Black-American female who visited the office today complaining of foul-smelling vaginal discharge, a burning sensation when urinating, and an itchy vulva X 7 days. The patient visited the office today because her symptoms were getting worse.

CC: 
“I have foul-smelling vaginal discharge, a burning sensation when urinating and an itchy vulva.”

HPI
: The pain began seven days ago with a burning sensation when urinating. She then started experiencing urination urgency and frequency. However, five days ago, the patient noticed a foul-smelling white discharge from her vagina, and her vulva suddenly became itchy. She noted that she had an unprotected one-night stand at a friend’s party and feared that she could be having STIs. She rates the vulva itchiness and the burning sensation at level 5/10 on a ten-point pain scale. She reported that the pain aggravates when urinating and reduces when bathing in cold water. However, the patient denies any medication used to resolve the symptoms.

     PMH:

          Medical Hx: Denies

          Surgical Hx: tonsillectomy (1992)

          Medications: Denies

          Allergies: NKA to food, latex, environment, or medications

    FAMILY HISTORY:

Patient states her parents (mother 60, father 63), sibling (sister 28), no children. Both parents are alive and live in Ghana (doesn’t know if they have any medical problems).

    SOCIAL HISTORY:

            General:
 She was born in Ghana but raised in the USA.

           Marital status: The patient is single; she recently broke up with her boyfriend. She has no children.

           Living situation: She lives alone in a rented apartment, which is located about 150 miles from her parent’s home. Her sister all lives with her parents. She lives in a safe environment close to her friends and colleagues.

            Children: None

            Occupation: She is an accountant in one of the restaurants in town.

            Leisure Patterns: Travelling and partying with friends.

            Social habits: Consumes at least a glass of wine when out with friends but denies smoking cigarettes.

            Spirituality: Believes in God but denies church involvement.

            Nutrition: She eats a balanced diet rich in fiber and vitamins. She also drinks at least eight glasses of water a day. 

            Sleep Patterns: The patient mostly works night shifts, so she sleeps during the day. She sleeps for at least 5 to  6 hours a day.

 

REVIEW OF SYSTEMS (Ness & Olsburgh, 2020
)

General: There has not been any significant difference in body size and weight for the past five years. She still wears the same size of the cloth. Denies fever, weakness, or fatigue.

 

Skin: Reports the skin is dry and warm. Denies lumps, itching, rashes, sores, and color change. However, she reports an itchy vulva X 7 days. Denies differences in her hair or nails. Denies difference in the color of moles or size.

HEENT

: Head: Denies dizziness, head injury, lightheadedness, or headache.

 
Eyes: Denies any changes in her eyesight. Makes no attempt to use glasses. The last eye check-up was in October 2020. Denies cataracts, spots, glaucoma, double or blurred vision, specks, excessive tearing, redness, or any pain. 
Ears: Denies discharge, earaches, tinnitus, infection, or vertigo. Denies utilization of hearing aids. 
Nose and Sinuses: Denies discharge and stuffiness. Denies sinus trouble, hay fever, or nose bleeding.

Throat
: 
Denies occasional gum bleeding or yellow teeth. Denies usage of dentures. Last dental check-up was in October 2020. Denies hoarseness, sore tongue, or repeated sore throats. Denies imprudent thirst or possessing dry mouth.

Neck: Denies stiffness in the neck, goiter, swollen glands, pain, or lumps.

Breasts: Denies nipple discharge, pain, lumps, or pain.

Respiratory: Denies dyspnea, sputum, wheezing, pleurisy, or cough. Fails to have a chest x-ray done. Denies possessing emphysema, cough, tuberculosis, bronchitis, or asthma.

Cardiovascular: Denies any problems with her heart, heart murmurs, High Blood Pressure, or rheumatic fever. Denies possessing edema, dyspnea, orthopnea, chest pain or discomfort, palpitations, or paroxysmal nocturnal dyspnea. Has at no time had EKG done.

Gastrointestinal: Denies nausea, heartburn, difference in appetite, or problems swallowing. Claims the stools are brown, and formed, and she has bowel movements every other day normally. Denies bleeding with defection or ache. No difference in bowel behaviors. Denies diarrhea, black or tarry stools, hemorrhoids, or constipation. Denies food intolerance or excessive belching or passing gas, and abdominal pain. Denies gall bladder problems, jaundice, or live. Denies Hepatitis. Cannot recall if she received the Hep B vaccine.

Urinary: Reports urination frequency and urgency (at least nine urinations in a day). Reports a burning sensation during urination. However, she denies urinary infections, hematuria, kidney stones, kidney pain, urethral colic, flank pain, incontinence, or suprapubic pain.

Genital: Menarche when she was 14 years old. She reports a regular period after approximately 28 days, and the period takes about 4 to 5 days. The period is normally heavier on the first two days. LMP: November 10th. Denies blood spots between periods. Denies dyspareunia, PMS, sores, STDs, or lumps. However, she complains of a foul-smelling white vaginal discharge. The vaginal discharge has a fish-like smell. She also complains of an itchy vulva.

Peripheral Vascular: Denies spider veins and inflammation in legs, calves, or feet. Denies varicose veins, leg cramps, and past clots in veins. The patient claims to have no difference in the color of her fingertips or toes during cold weather/temperatures. Denies tenderness or any swelling.

Musculoskeletal: Denies loss of sensation, paresthesia, and muscle weakness, no severe or progressive neurological deficit in the lower extremity. Denies history of cancer or spinal infections, or risk factors. Denies joint aches and other muscles, arthritis, hx of gout, or stiffness. Denies weakness, rash, fever, weight loss, anorexia, and chills.

Psychiatric: Denies depression, tension, nervousness, memory changes, or mood changes.

Neurologic: Denies speech complications, the difference in mood or attention. Denies changes in judgment, insight, memory, or orientation. Denies seizures, blackouts, fainting, headaches, weakness, loss of sensation or numbness, vertigo, paralysis, pins and needles or tingling, or other deliberate movements or tremors.

Hematologic: Denies Past transfusions, bleeding, or easy bruising and anemia.

Endocrine: Denies too much hunger and thirst. Denies too much sweating, cooperatives, and responses appears concerned without signs of acute distress.

       OBJECTIVE DATA: (Ness & Olsburgh, 2020)

Vital signs: T: (oral) 98º; P: 81; R: 20; BP: 124/74; Ht: 68”, Weight: 130 lb (BMI: 21 )

General: Skin warm and dry w/o discoloration or pallor, A/O x 3, appropriate responses, cooperative, appears concerned w/o signs of acute distress.

Physical Examination findings

Skin: Skin is supple, pink, and warm; lesions not seen.

HEENT: EOMs intact, PERRLA, Normocephalic, and fundoscopic; red reflex present, hemorrhage or no nicking. TM intact bilaterally, light reflex +pearly. Neck supple, nares patent. Pharynx: swallows easily, lacks erythema; Neck; thyroid nonpalpable, without carotid bruits.

 Normocephalic, PERRLA, EOMs intact, and fundoscopic: red reflex present, no nicking or hemorrhage. TM intact bilaterally, pearly with + light reflex. Nares patent, neck supple. Pharynx: swallows w/o difficulty, no erythema; Neck: thyroid nonpalpable, no carotid bruits.

 Lungs: Good expansion with the symmetric thorax. Resonant lungs. Vascular breath sounds; no rhonchi, rales, or wheezes.

Cardiovascular: Carotid upstrokes are brisk, lacking bruits. The PMI is tapping in the fifth intercostal space 7cm lateral to the midsternal line. S2 on auscultation is less loud than S1. No extra sounds or murmurs. Extremities lack edema and are warm. No statis difference or varicosities. Calves are non-tender and supple. No abdominal bruits or femoral. Dorsalis pedis, radial, popliteal, brachial, and posterior tibial pulses are 2+. Symmetric and brisk.

 Breasts: Deferred. Focused.

Abdomen: In all four quadrants, the abdomen is flat with active bowel sounds. It is nontender and soft; no hepatosplenomegaly or no masses. No tenderness of CVA.

Genitalia: Has evenly distributed thin hair. Positive for thin white discharge with a fish-like odor during the inspection. Pink vaginal walls

Rectal: Deferred

Musculoskeletal: No deformities of joint. Hands, elbows, knees, wrists, ankles, and shoulders have positive ROM. 

Gait/Posture
: At 15 degrees, it is flexed forward. Toe and heels are walking intact. 

Spinal column
: No lordosis, kyphosis, or scoliosis; unable to rotate or extend. 

Lateral movement
: bilaterally to 20º. All trials at ROM come up with an ache. Crossed SLR negative, Patrick test negative, and straight leg raise negative. No major motor weaknesses have been observed on dorsiflexion, ankle plantar flexors, evertors, and Knee extension. No tenderness of CVA.

Neurologic: Cooperative, relaxed and alert. The thought process is coherent. Oriented to place, time, and person. Intact cranial nerves II to XII intact. Good tone and muscle. Thought strength of 5/5. Intact rapid alternating movements and point-to-point movements. Stable gait. Romberg negative, light touch, vibration, stereognosis intact pinprick. Plantar reflexexdown gongs are symmetric with reflexes 2+.

 

ASSESSMENT: (Schuster et al., 2020)

Diagnosis:

1. B.96-Bacterial Vaginosis

    

Differentials:

1.
B.96-Bacterial Vaginosis: A burning sensation during urination, white vaginal discharge with a fish-like foul smell. A history of multiple sexual partners. Wet mount test
: tested positive for clue cells.
 Cervical pH: 5.3-
 indicating higher ph.

2.
B37.3-Vaginal Candidiasis: white vaginal discharge. An itchy vulva.

3.
N39.0-Urinary Tract Infection: Urination urgency and frequency. A burning sensation during urination.

4.
A59.9-Trichomoniasis: White vaginal discharge

   

PLAN: (Hazra et al., 2022)

    Diagnostic: The following lab test was conducted on 11/24/2022

·
Urinalysis test: negative results
.

·
Wet mount: result reveals clue cells

    Therapeutic: Pharmacological:

Metronidazole 500 mg orally 2 times/day for 7 days (Wang et al., 2019).

Non-pharmacological:

Metronidazole 1.3% vaginal gel in a single dose
   

Patient Education:

1. Avoid wearing panties with fragrance.

2. Avoid using soap with irritating substances.

3. Abstain from sexual intercourse until the symptoms fully recover.

4. Use protection during intercourse.

5. Ask sexual partners to seek medical attention.

    Referral: None

    Follow-Up: She was asked to return to the clinic if the symptoms do not resolve in three to four days.

  Evidence-Based Practice: (Hazra et al., 2022)

The condition occurs due to the imbalance of the vaginal biome’s natural bacteria. It is also related to having multiple sexual partners, douching, and imbalance in the vaginal ph. The symptoms of this disease are white or grey vaginal discharge, a fish-like foul smell from the vagina, vaginal itchiness, and a burning sensation during urination.

National guidelines for bacterial vaginosis management (Hazra et al., 2022):

Inform the patient that the condition resolves within 4-5 days after medication, but the patient should follow the education guidelines provided.

Therapy

· Drink plenty of water.

· Avoid substances with fragrance around the vagina

· Avoid sexual intercourse during medication.

Referral

· Usually, no surgery is required, but if the symptoms persist, further tests should be considered.

Medication Strategies

Metronidazole 500 mg orally 2 times/day for 7 days

OR

Tinidazole 2 g orally once daily for 2 days

OR

Clindamycin 300 mg orally 2 times/day for 7 days

Testing

·
Cervical pH of >4.5

·
Whiff test: evidence of fish-like smell

·
Wet mount test: evidence of clue cells. 
 

 

References:

Coudray, M. S., & Madhivanan, P. (2020). Bacterial vaginosis—A brief synopsis of the literature. 
European Journal of Obstetrics & Gynecology and Reproductive Biology, 
245, 143-148.

Hazra, A., Collison, M. W., & Davis, A. M. (2022). CDC sexually transmitted infections treatment guidelines, 2021. 
JAMA, 
327(9), 870-871.

Ness, D., & Olsburgh, J. (2020). UTI in kidney transplant. 
World Journal of Urology, 
38(1), 81-88.

Schuster, H. J., de Jonghe, B. A., Limpens, J., Budding, A. E., & Painter, R. C. (2020). Asymptomatic vaginal Candida colonization and adverse pregnancy outcomes including preterm birth: a systematic review and meta-analysis. 
American Journal of Obstetrics & Gynecology MFM, 
2(3), 100163.

Van Gerwen, O. T., Craig‐Kuhn, M. C., Jones, A. T., Schroeder, J. A., Deaver, J., Buekens, P., … & Muzny, C. A. (2021). Trichomoniasis and adverse birth outcomes: a systematic review and meta‐analysis. 
BJOG: An International Journal of Obstetrics & Gynaecology, 
128(12), 1907-1915.

Wang, Z., He, Y., & Zheng, Y. (2019). Probiotics for the treatment of bacterial vaginosis: a meta-analysis. 
International journal of environmental research and public health, 
16(20), 3859.