Vaginal Discharge And Burning Discussion Paper

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Vaginal Discharge And Burning Discussion Paper

Respond  your colleagues’ post and explain how you might think differently about the types of diagnostic tests you would recommend and explain your reasoning. Use your Learning Resources and/or evidence from the literature to support your position. NEED 2 Scholarly references and APA format. SOAP note below.Vaginal Discharge And Burning Discussion Paper

 

Focused Soap Note

Patient Information:

Initials: S.J,      Age: 24,         Sex: Female,         Race: Not provided

S.

CC: “Vaginal discharge and burning.”

HPI: 24-year-old S.J female GoPoLo presents to the clinic with vaginal discharge and burning for one week. She reports that her boyfriend recently tested positive for chlamydia. S.J. is sexually active. She denies having other sexual partners.

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Current Medications: Multivitamin and LoEstrin daily.

Allergies: NKDA.

PMHx:

Depression

Anxiety

Soc & Substance Hx: S.J. reports social alcohol use. She denies the use of tobacco and recreational drugs.

Fam Hx:

Mother is alive with hypothyroidism and breast cancer.

Father is alive with hypertension, diabetes, and hyperlipidemia.

Paternal grandfather is alive with a history of prostate cancer.

Sister has type 1 diabetes.

Brother is alive with no pertinent medical history. Vaginal Discharge And Burning Discussion Paper

Surgical Hx: None.

Mental Hx: Depression and anxiety with unknown treatment.

Violence Hx: Unknown.

Reproductive Hx: LMP unknown, no previous pregnancy. LoEstrin daily for oral contraceptives. Menstrual history unknown.

ROS

GENERAL: Denies weight loss, fever, chills, or weakness.

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: S.J denies chest pain, palpitations, or a history of murmurs. She states that she exercises regularly.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: S.J. denies abdominal pain, nausea, vomiting, or diarrhea. No loss of

appetite. Regular bowel movements daily.

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: History of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY: She reports vaginal burning and burning on urination. She states that her menstrual cycles are regular, with no heavy bleeding or cramping. LMP: 2/12/2023. Vaginal Discharge And Burning Discussion Paper

REPRODUCTIVE: S.J. reports vaginal discharge and burning. She is sexually active with her boyfriend. She denies pain during sexual intercourse

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Vitals: Temp- 97.6, BP-133/67, P-63, weight- 148 lbs, height- 5’6

Physical exam:

GENERAL: Well-developed, alert, and oriented.

Neck: lymph nodes grossly normal

Lungs/CV: Chest is clear to auscultation bilaterally, with normal respiration, rhythm, and depth upon

exam

Abdomen: Soft, non-tender to palpation, and non-distended. Normoactive bowel sounds in all four quadrants.

Breast: normal breast exam

Gynecological: VVBSU WNL. The cervix is firm and smooth with a large amount of yellow,

watery discharge. Uterus retroverted, non-tender, and mobile. Adnexa WNL.

Diagnostic results:

Vaginal wet mount – Candida present.

NAAT (Vaginal swab)

Urine pregnancy test – negative.

The most appropriate method for testing chlamydia is NAAT. According to Hsu (2021), a vaginal swab is preferred for collecting specimens for the NAAT. The vaginal wet mound indicated candida presence and is the most appropriate method to diagnose vulvovaginitis. In addition, since the patient’s LMP is unknown, it is important to perform a urine pregnancy test. Vaginal Discharge And Burning Discussion Paper

A.

Chlamydia trachomatis infection (A74.9). Chlamydia trachomatis is a common sexually transmitted infection that manifests with vaginal discharge, bleeding with intercourse and urinary symptoms such as urgency, frequency and dysuria. Upon physical examination, the presence of mucopurulent cervical discharge, endocervical bleeding, and vulva erythema may be observed. According to Li et al. (2023), if left untreated, chlamydia may result in other complications, such as pelvic inflammatory disease (PID). Based on S.J.’s case study, the presence of vaginal discharge and burning, as well as large amounts of cervical discharge noted during a physical examination, may be considered the primary diagnosis.

Candida vulvovaginitis (B37.3). This is commonly known as a yeast infection. It mainly occurs in the vulva and vaginal mucosa. It is caused by the overgrowth of a fungus known as candida albicans. According to Willems et al. (2020), symptoms include vaginal itching, burning during urination, and erythema on the vulva as well as a thick white discharge that looks like curd. This is an appropriate differential, considering the patient’s symptoms, such as burning and itching. However, the patient has yellow-like vaginal discharge, which rules out candida vulvovaginitis. Vaginal Discharge And Burning Discussion Paper

Neisseria gonorrhoeae infection (A54.9). This is a sexually transmitted infection that manifests with similar symptoms as chlamydia. Jefferson et al. (2021) state that symptoms of gonorrhea include vaginal discharge, dysuria, uterine bleeding, lower abdominal pain, and dyspareunia. If left untreated, it may cause pelvic inflammatory disease, infertility as well as chronic pain. Gonorrhea is considered a differential in S.J.’s case because of her presenting symptoms. However, she does not present with abdominal pain; hence, this is ruled out.

Bacterial Vaginosis (N77.1). S.J. presents with symptoms that indicate an infection of the vagina and vulva because of vaginal discharge and burning. Therefore, BV is an appropriate differential. Symptoms of BV include a grey-thin vaginal discharge with a strong fishy odor (Khedkar & Pajai, 2022). However, BV does not present with burning or vulva erythema, thereby ruling out BV.

P. Vaginal Discharge And Burning Discussion Paper

Diagnostic studies

CT/NG NAAT vaginal swab

Wet

Pharmacological interventions

Doxycycline 100 mg orally twice a day for seven days.

Patient Education

  • Advise patient to avoid intercourse while on treatment.
  • Educate the patient on the importance of adhering to medication and advise her to continue taking the antibiotics to complete the dosage even when the symptoms have alleviated.
  • Advise the patient to practice safe sex after treatment.

Referrals: None.

Follow up

Return to the clinic if symptoms persist or worsen. Vaginal Discharge And Burning Discussion Paper

Reflection

            SJ presented to the clinic with vaginal discharge and burning. The patient reported a history of anxiety and depression and stated that her boyfriend tested positive for chlamydia. Therefore, she must be treated. However, a physical exam and diagnostic tests were done before treatment to confirm the correct diagnosis. In this case, to test for chlamydia, the recommended method is NAAT. This included performing vaginal swabs to obtain the specimen for NAAT. Hsu (2021) states that the NAAT is the most appropriate method to test for chlamydia and gonorrhea. The wet mount revealed the presence of candida, which can be a confirmation of candida vulvovaginitis. In addition, because the date of LMP was not known, it was essential to conduct a urine pregnancy test (UPT). The UPT was performed to determine whether SJ was pregnant or not. It involves checking a sample of her urine for the hormone known as chorionic gonadotropin (hCG). In this case, SJ’s UPT was negative, indicating no pregnancy. Vaginal Discharge And Burning Discussion Paper

Based on this case, the primary diagnosis was chlamydia trichomatis, while the differentials included Neisseria gonorrhea, candida vulvovaginitis, and BV. The diagnostic testing was ordered in this patient’s case based on the differential diagnosis. This helped to narrow it down to one diagnosis. For example, the CT/NG NAAT vaginal swab and Wet mount testing were conducted to identify the diagnosis. These diagnostic tests are important because the patient may have multiple infections, and since her boyfriend tested positive for chlamydia, it is crucial to test for the same. In addition, chlamydia and gonorrhea are often co-infections because they present with similar symptoms (Schuiling, K. D., & Likis, 2022). Therefore, it is vital to determine the exact disease based on the symptoms and using diagnostic studies.

I agree with the preceptor’s treatment of SJ since the treatment is geared towards addressing the primary diagnosis. However, it is important to ask more questions to obtain all the important patient information (Schuiling & Likis, 2022). Therefore, I would include additional questions in this patient’s case. The following are some of the questions I would ask SJ: Vaginal Discharge And Burning Discussion Paper

  1. Can you describe the color, texture, and odor of the vaginal discharge?
  2. Do you have any exacerbating or relieving factors? Are there treatments used? If so, what are they?
  3. Do you have any other related symptoms?
  4. When were you diagnosed with anxiety and depression, and what medications have you used?
  5. How long do your menstrual cycles last?

            I would ask the patients these additional questions to create an in-depth patient history. For instance, it is important also to find out whether the patient has any concerns about the personal safety of intimate partner violence to intervene and address the concerns, considering the partner has already tested positive for chlamydia, indicating he could be unfaithful. In addition, it is also important to ask the patient about their last LMP and other pregnancy concerns.

 

                                                                                             References

Hsu, K. (2021). Clinical manifestations and diagnosis of Chlamydia trachomatis infections UpToDate. https://www.uptodate.com/contents/clinical-manifestationsand-diagnosis-of-chlamydia-trachomatis infections?search=chlamydia%20and%20gonorrheadiagnosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1835257006Links to an external site.

Jefferson, A., Smith, A., Fasinu, P. S., & Thompson, D. K. (2021). Sexually transmitted neisseria gonorrhoeae infections—update on drug treatment and vaccine development. Medicines, 8(2), 11. https://doi.org/10.3390/medicines8020011 Vaginal Discharge And Burning Discussion Paper

Khedkar, R., & Pajai, S. (2022a). Bacterial vaginosis: A comprehensive narrative on the etiology, clinical features, and management approach. Cureus. https://doi.org/10.7759/cureus.31314

Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.

Willems, H. M., Ahmed, S. S., Liu, J., Xu, Z., & Peters, B. M. (2020a). Vulvovaginal candidiasis: A current understanding and burning questions. Journal of Fungi, 6(1), 27. https://doi.org/10.3390/jof6010027

 

 

Class RESOURCES

  • Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.
    • Chapter 17, “Breast Conditions” (pp. 337-349)
    • Chapter 18, “Alterations in Sexual Function” (pp. 353-364)
    • Chapter 20, “Infertility” (pp. 383-398)
    • Chapter 21, “Gynecologic Infections” (pp. 401-432)
    • Chapter 22, “Sexually Transmitted Infections” (pp. 437-466)
  • Reproductive Health Access Project (2020). Your birth control choicesLinks to an external site.. https://www.reproductiveaccess.org/wp-content/uploads/2014/06/2020-09-contra-choices.pdf
  • Office of Women’s Health: Womenshealth.gov. (2017). Birth control methodsLinks to an external site.. https://www.womenshealth.gov/a-z-topics/birth-control-methods Vaginal Discharge And Burning Discussion Paper

CLINICAL GUIDELINE RESOURCES

As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for CDC – zika in pregnancy).

  • American Cancer Society, Inc. (ACS). (2020). Information and Resources about for Cancer: Breast, Colon, Lung, Prostate, SkinLinks to an external site.. https://www.cancer.org/
  • American College of Obstetricians and Gynecologists (ACOG)Links to an external site.. (2020).  https://www.acog.org/
  • American Nurses Association (ANA). (n.d.). Lead the profession to shape the future of nursing and health careLinks to an external site.. https://www.nursingworld.org/
  • Centers for Disease Control and Prevention. (CDC)Links to an external site.. (n.d.). https://www.cdc.gov/
  • HealthyPeople 2030. (2020). Healthy People 2030 FrameworkLinks to an external site.. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework
  • The American Association of Nurse Practitioners (AANP)Links to an external site.. (2020). https://www.aanp.org/ Vaginal Discharge And Burning Discussion Paper