Postcoital Bleeding and Sore Throat Essay

HPI: S.L is a 24-year-old Caucasian female presenting to the clinic for regular care. S.L. relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for the past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies. Postcoital Bleeding and Sore Throat Essay

Current Medications: Pamprin OTC, Tylenol PRN fever

What is the dosage? How frequently are you taking it? What is the length of time used? What is the reason for use? When was your last dose? Any other prescribed; over the counter medications or herbal remedies you are taking? Postcoital Bleeding and Sore Throat Essay

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Allergies: Denies any allergies

Do you have any food and/or environmental allergies? Latex allergies? If so, please describe what occurred.

PMHx: Denies any medical or surgical history. Any recent changes with your past medical history or surgical history? Have you had any hospitalizations? Are you up to date with your immunizations? HPV, Influenza, Tetanus? Postcoital Bleeding and Sore Throat Essay

Soc & Substance Hx: She works full-time as an administrative assistant, and relates she loves her job. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, ETOH only on weekends, 6-8 hard liquor/ daily, and marijuana smoking. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Postcoital Bleeding and Sore Throat Essay

Do you text/ use your cellphone while driving? What are your living arrangements? Are you married or single? Are you currently in a relationship? How long have you been in your current relationship? Do you have any children? Do you have a support system? Are you interested in smoking counseling / cessation? Have you tried cutting down the amount of PPD that you smoke? Ask the CAGE questions in relation to her alcohol intake. Postcoital Bleeding and Sore Throat Essay

Fam Hx: Non-contributory. Any changes with your family history?

Surgical Hx: Denies any surgical history. Any changes with your surgical history? Postcoital Bleeding and Sore Throat Essay

Mental Hx: Do you have any history of mental illness? If so, what is the diagnosis and treatment? Any thoughts or plans of self-harm presently or in the past? Do you have any current concerns? Do you have any feelings of anxiety or depression? Do you feel hopeless? Any questions or concerns regarding your mental health you would like to talk about? Postcoital Bleeding and Sore Throat Essay

Violence Hx: Have you ever been sexually, physically or verbally abused? Do you have any history of neglect? Do you feel safe in your current relationship? Do you feel safe at home? Any concerns with your safety?

Reproductive Hx: Onset of menses at age 13, menses every 28-32 days, lasting 4-6 days and using 3 tampons daily. She has some cramping during her menses for which she takes otc Pamprin.

Have you ever had a pelvic exam or pap smear? Are you up to date with your pap smears?  Postcoital Bleeding and Sore Throat Essay When was your last pap smear and pelvic exam? Do you have any children? Have you ever been pregnant before? Any miscarriages, ectopic pregnancies, abortions? When was your last menstrual period? How severe is your cramping? Do you experience clotting with your menses? How is your flow, light or heavy? Are you sexually active? When was your last unprotected intercourse? Do you have sex with men, women or both? How many sexual partners do you have? Have any of your sexually partners been exposed to STDs? If so, recently? Are they seeking treatment? Have you seeked treatment before? Do you experience any pain with intercourse? What form of intercourse do you perform? vaginal, oral, and/or anal? Are you currently using any contraceptive measure, such as birth control or condoms? What contraceptives have you used in the past, if any? How long was the duration of use? What was your reasoning for discontinuing it? Do you have history of STDs? Any sexual concerns you would like to address? Postcoital Bleeding and Sore Throat Essay

ROS:

GENERAL: Denies any weight loss, fever.

Have you experienced any chills, weakness, or fatigue? I noticed your weight is the same from last year. Are you happy with your current weight? Do you have any problems with gaining weight? How is your appetite? Describe your diet. Postcoital Bleeding and Sore Throat Essay

HEENT: Eyes: Are you having any visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: Any ear pain, drainage, hearing loss, sneezing, congestion or runny nose? Complaints of a sore throat x 3 weeks. Postcoital Bleeding and Sore Throat Essay

SKIN: Do you have any rashes or experiencing any itching?

CARDIOVASCULAR: Do you or have you experienced any chest pain, chest pressure, or chest discomfort. Any palpitations?

RESPIRATORY: Have you experienced any shortness of breath, coughing, or sputum.

GASTROINTESTINAL: Are you experiencing any nausea, vomiting, or diarrhea? Have you had any history of anorexia? Are you having any abdominal pain or bleeding? Postcoital Bleeding and Sore Throat Essay

BREAST: It would be important to ask if the patient performs self-breast exams regularly. When was her last breast exam? Is she experiencing pain or tenderness? Has she experienced any nipple discharge? Postcoital Bleeding and Sore Throat Essay

GENITOURINARY: Are you experiencing any frequency, urgency, retention or difficulty when urinating? Any foul odor noted? Are you currently pregnant? When was your LMP?

HEMATOLOGIC: Do you have any history of anemia, bleeding, or bruising?

LYMPHATICS: Do you have any enlarged nodes? Do you have history of splenectomy?

PSYCHIATRIC: Do you have any history of mental illness? Postcoital Bleeding and Sore Throat Essay

REPRODUCTIVE: Complaints of postcoital bleeding x 6 weeks.

Are you pregnant or any recent pregnancies? Are you sexually active? Please describe your postcoital bleeding.

ALLERGIES: Do you have history of asthma, hives, eczema, or rhinitis? Postcoital Bleeding and Sore Throat Essay

O.

Height 5’ 6” Weight 118 (BMI 19.04), Temp 97.8, BP 112/64 P 68 

General: Patient is a 24 year old Caucasian female, well-groomed, alert and oriented historian. Postcoital Bleeding and Sore Throat Essay
HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened.
Lung: clear to auscultation
CV: regular sinus rhythms without murmur or gallop
Abd: soft, non-tender, liver normal,
Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.
VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
Cervix: friable, some petechia no cervical motion tenderness.
Uterus: mid mobile, non-tender
Adnexa: without masses or tenderness Postcoital Bleeding and Sore Throat Essay
Perineum: wnl
Rectum: wnl
Extremities: full rom, skin clear, no edema, reflexes 1+.
Neurological: CN II-12 grossly intact.
Diagnostics:

Nucleic acid amplification tests (NAATs) are commonly used and recommended by the CDC as the most reliable testing method for diagnosing urogenital chlamydia and gonorrhea infections with timely results, allowing for expedited evidence-based treatment (Fawcett, Williams, Johnson & Ramsey, 2022).
Vaginal and cervical swab – postcoital bleeding and slight frothy yellow discharge by cervix
Throat swab – complaints of a sore throat x 6 weeks and some anterior cervical adenopathy bilaterally, and throat appears reddened.
Urine pregnancy test – dependent on patients stated LMP and to rule out unknown pregnancy Postcoital Bleeding and Sore Throat Essay
A.

Differential Diagnoses

Primary Diagnosis: Gonorrhea

There is increasing evidence of pharynx to genital transmission of gonorrhea (Javanbakht, Westmoreland & Gorbach, 2018). Common disease presentation includes penile or vaginal discharge, unusual vaginal bleeding, or dysuria in sexually active patients. Certain factors, such as having more than one sexual partner, unprotected sex, and men who have sex with men, place individuals at a higher risk of STD exposure (Fawcett, Williams, Johnson & Ramsey, 2022). Postcoital Bleeding and Sore Throat Essay Both chlamydia and gonorrhea are often asymptomatic diseases, yet the infections are still highly transmissible during oral, anal, or vaginal intercourse or through vertical transmission during childbirth (Fawcett, Williams, Johnson & Ramsey, 2022). Postcoital Bleeding and Sore Throat Essay

Symptoms:

Sore throat
Redness in the throat
Fever
Swollen lymph nodes in the neck
Painful or burning sensation when peeing
Increased vaginal discharge; and
Vaginal bleeding between periods.
P. Postcoital Bleeding and Sore Throat Essay

Although there are growing concerns regarding resistance of N. gonorrhea to antibiotics, treatment should not be postponed while awaiting confirmatory results if same-day treatment is available for patients with STD concerns or partners with a known exposure (Fawcett, Williams, Johnson & Ramsey, 2022). Efforts to control STD transmission will be important. Postcoital Bleeding and Sore Throat Essay

Treatment: 250 mg Ceftriaxone IM x 1 dose and 2g Azithromycin PO x 1as well as doxycycline 100 mg BID x 7 days, if Chlamydia is not ruled out Postcoital Bleeding and Sore Throat Essay

According to Dresser & Wilby (2021) the current recommended treatment for gonorrhea by the Centers for Disease Control and Prevention is a single intramuscular injection of 250 mg ceftriaxone plus a single oral 2-g dose of azithromycin. If coinfection with chlamydia cannot be excluded, concurrent treatment with a 7-day course of doxycycline, 100 mg twice a day, should also be provided (Fawcett, Williams, Johnson & Ramsey, 2022). Postcoital Bleeding and Sore Throat Essay

Referrals to other health care providers: not applicable at this time

Education on safe-sex and monogamous. Avoid sexual contact, including oral sex and kissing, for seven days after completing treatment. Avoid sharing food and drinks. Avoid drinking alcohol while on antibiotics. Take medication as prescribed. Postcoital Bleeding and Sore Throat Essay

Disposition of the patient: Pt will follow up in the office in 3 months for a follow up visit and re-testing for STDs. Pt is aware to contact the office, if any complications or concerns are noted prior to her scheduled visit. Postcoital Bleeding and Sore Throat Essay