Case Study: Chlamydia, Trichomoniasis ,Bacterial Vaginosis
Instructions
Review the Learning Resources for this week, with a focus on the media program related to basic microscope skills. Also, consider revisiting the media programs found in Week 1 Learning Resources.
Carefully review the clinical guideline resources specific to your assigned case study.
Use the Focused SOAP Note Template found in the Learning Resources to support the discussion. Complete a FOCUSED SOAP note and critically analyze it, with a focus on the diagnostic tests. Please post your SOAP note. This will help you develop your differential diagnosis and additional questions.
By Day 3, please post your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns, and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations.
Case Study: Charlene Baja, a 22-year-old G0 P0 L0, presents to the clinic today with burning urination and fishy discharge for 3 days. She mentions having a new boyfriend, and they are engaging in unprotected intercourse. She denies any other partners besides him. Her medical history is remarkable for anxiety and depression. Her surgical history is unremarkable. Socially, she consumes alcohol but denies tobacco and recreational drugs.
She has no known drug allergies and takes a multivitamin and Sprintec daily for oral contraception. Family history reveals her mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer, and her sister has type 1 diabetes. Her father has HTN, type 2 diabetes, and hyperlipidemia. Charlene has one brother with no medical history.
- Height: 5′ 5″ Weight: 148 (BMI 24.6), BP: 132/68 P: 62
- HEENT: Within normal limits
- Neck: Lymph nodes grossly normal
- Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam
- Breast: Normal breast exam
- Abd: Suprapubic tenderness
- VVBSU: Within normal limits
- Cervix: Firm, smooth, copious amounts of green discharge present
- Uterus: Retroverted, mobile, non-tender
- Adnexa: Within normal limits
- Microscopic evaluation of vaginal fluid (wet mount) shows trichomonas (motile organisms)
Solution
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Miss C, Age- 22 years, Sex- Female, Race-African-American
S.
CC (chief complaint): Miss C has been having a burning sensation and vaginal discharge for the past 1 week.
HPI: The patient has been having a burning sensation and vaginal discharge.
Location: vagina
Onset: 1 week ago
Character: burning
Associated signs and symptoms: yellow watery vaginal discharge
Timing: most of the time
Exacerbating/relieving factors: N/A
Severity: 9/10 scale
Current Medications: Multivitamins and Srintec for oral contraception
Allergies: No known drug or food allergies
PMHx: The patient has a history of anxiety and depression. She had her last tetanus jab in July 2021.
Soc & Substance Hx: The patient is a college student who works part-time as a barrister in a local coffee shop. She has a boyfriend who recently found out that he was positive for chlamydia. She uses social alcohol but denies the use of tobacco or any recreational drugs.
Fam Hx: The patient’s mother is alive but with breast cancer in remission and hypothyroidism. Her paternal grandfather has prostate cancer. Her father has hypertension, diabetes type 2, and hyperlipidemia.
Surgical Hx: No history of surgery
Mental Hx: The patient has a history of anxiety and depression.
Violence Hx: No history of violence or self-harm
Reproductive Hx: The patient is sexually active with one partner. She is on an oral contraceptive; Srintec daily.
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. Chest is clear to auscultation bilaterally, normal respiration rhythm and depth
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
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: Has a history of depression and anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Has yellow watery vaginal discharge
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vitals: Height 5’5” weight 148 (BMI 24.6), BP 132/68, P 62
Reproductive: yellow watery vaginal discharge
Genitourinary: Burning on urination
Diagnostic results:
Nucleic acid amplification tests (Redelinghuys et al., 2020).
Wet mount
Whiff test
Vaginal ph
A.
Based on the patient’s history, her boyfriend whom they are sexually active has been recently diagnosed with chlamydia which puts her at an increased risk of infection. Her chief complaint of pain during urination and vaginal discharge for the past one week should be reasons for testing for chlamydia.
Differential Diagnoses
Chlamydia
Chlamydia is the patient’s primary diagnosis based on her sexual history and presenting symptoms. The infection is caused by the bacterium Chlamydia trachomatis and is the most commonly reported bacterial infection in the United States. Some of the signs and symptoms of the chlamydia trachomatis infection include painful urination, vaginal discharge, painful sexual intercourse, and bleeding between periods among others. Miss C presents with two of the above symptoms.
Trichomoniasis
Trichomoniasis is a sexually transmitted infection caused by a protozoan parasite known as Trichomonas vaginalis. The infection results in a foul-smelling vaginal discharge, painful urination, and genital itching among women (Van Gerwen & Muzny, 2019). Some of the associated risk factors of getting the infection include having unprotected sexual intercourse and multiple sexual partners.
Bacterial Vaginosis
Bacterial vaginosis is a type of infection that is caused by an overgrowth of the bacteria found naturally in the vagina (Redelinghuys et al., 2020). Some of the factors that increase a person’s risk of infection include unprotected sexual intercourse. Some of the common symptoms are vaginal odor, itching, and abnormal vaginal discharge.
The patient’s health profile indicates that she suffers from anxiety and depression which communicates the need to incorporate therapeutic interventions that would result in optimal health status. The most suitable management plan would be the use of antibiotics. The patient could receive a one-time dose or multiple times daily for five to ten days.
Chlamydia’s first-line treatment is azithromycin single dose or doxycycline for 7 days (O’Connell & Ferone, 2016).
Trichomoniasis can be managed using a single 2-gram dose of oral tinidazole or oral MTZ 500 mg twice daily for 7 days.
Bacterial vaginosis can be treated using oral metronidazole 500 mg twice daily for 7 days, metronidazole 0.75% gel intra-vaginally at bedtime for 5 days, or clindamycin cream 2% at bedtime for 2 days (Jones, 2019).
Health education would be important especially on the need to abstain from sexual intercourse during treatment and the need to use protection. Similarly, the effectiveness of oral contraception would be lowered if one is taking antibiotics hence the need to use additional protective measures like condoms. It would be important to educate the patient that the infection could be passed back and forth between sexual partners hence the need for protected sex and having one sexual partner.
Follow up visit after three weeks is important to check on the patient’s wellbeing, response to drugs, and overall change of perception and behavior concerning sexually transmitted diseases.
Reflection
The patient understood and agreed with the treatment plan. She also agreed to discuss the side effects of medications based on her history of anxiety and depression. The patient verbalizes having understood her condition, factors linked to it, and her responsibility to prevent future infections. The patient learned the importance of protected sex as a method of disease prevention. The patient who is 22 years old is prone to having multiple sexual partners. Similarly, she also takes social alcohol which exposes her to illicit sexual behavior.
References
Jones, A. (2019). Bacterial vaginosis: a review of treatment, recurrence, and disparities. The Journal for Nurse Practitioners, 15(6), 420-423.
O’Connell, C. M., & Ferone, M. E. (2016). Chlamydia trachomatis Genital Infections. Microbial cell (Graz, Austria), 3(9), 390–403. https://doi.org/10.15698/mic2016.09.525
Redelinghuys, M. J., Geldenhuys, J., Jung, H., & Kock, M. M. (2020). Bacterial vaginosis: current diagnostic avenues and future opportunities. Frontiers in cellular and infection microbiology, 10, 354.
Van Gerwen, O. T., & Muzny, C. A. (2019). Recent advances in the epidemiology, diagnosis, and management of Trichomonas vaginalis infection. F1000Research, 8, F1000 Faculty Rev-1666. https://doi.org/10.12688/f1000research.19972.1