Case Study Discussion: Common Gynecologic Conditions, Part 1- Case Study 2: Case Study: STI Investigation-Focused SOAP Note
Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, and diagnostic approaches, as well as to the development of treatment plans.
For this Case Study Discussion, you will once again review a case study scenario to obtain information related to a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop treatment and management plans.
- By Day 1 of this week, you will be assigned to a specific case study scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
- Review the Learning Resources for this week and specifically review the clinical guideline resources specific to your assigned case study.
- Use the Focused SOAP Note Template found in the Learning Resources to support your Discussion.
By Day 3
Based on the case study scenario provided, complete a comprehensive well-woman exam and critically analyze the exam to focus attention on the diagnostic tests. Then,
Post your primary diagnosis. Include the additional questions you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask for. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)
Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations.
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues’ posts on two different days 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.
Case Study 2: Case Study: STI Investigation
Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full-time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. 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. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has some cramping during her menses for which she takes otc Pamprin. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for 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.
Susan’s vital signs are taken and were temperature 97.8, pulse 68, BP 112/64, height 5’6” and weight 118 lbs. (which was the same as last year). BMI 19.04
- 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
- Perineum: wnl
- Rectum: wnl
- Extremities: full rom, skin clear, no edema, reflexes 1+.
- Neurological: CN II-12 grossly intact.
- What other information do you need?
- What testing would you perform/order?
- What are your initial thoughts for diagnosis?
Susan relates she “sometimes” uses condoms but feels like she gets irritation from them. She does not desire pregnancy, but not sure what type of other options are available. She relates she has had 13 partners in the last 12 months, her partners have all been male except one in the past year. She has never received the Gardasil vaccine as her mother doesn’t believe it’s been tested enough and reports no history of STI’s but doesn’t remember being tested in the past.
She has not felt the need to cut down on her drinking, feeling that “everyone drinks like she does.” She is occasionally awakened in the am sleeping next to a stranger but does not remember how it happened.
She has been occasionally annoyed about her parent’s criticism about drinking but has been better since she moved into her own apartment. She relates she does not feel guilty about drinking. She has never taken an “eye opener.”
Pap returns as normal, with trichomonads noted
Throat culture returns positive for gonorrhea
Vaginal culture returns positive for chlamydia
Wet mount shows many WBC’s, many trichomonads, positive clue cells, positive amine (whiff test)
RPR negative, hepatitis c negative, HIV negative’
What are your next steps?
Episodic/Focused SOAP Note
Age: 24 years old
CC (chief complaint): the patient is in office for regular care. S.L. complains of post-coital bleeding (last six weeks), a sore throat (past three weeks) and a one day fever that resolved with Tylenol. She is otherwise doing okay.
HPI: S.L. is a 24 year old Caucasian female who presented to the office for regular care with new complaints of post coital bleeding for the past six weeks and a sore throat for the past three weeks. The post-coital bleeding occurred after every episode of sexual intercourse and was associated with dyspareunia on deep and superficial penetration and lower abdominal pain. She denied using any sexual instruments during intercourse but admitted to changing partners whom she didn’t know whether or not they had a history of STIs. She also reported a foul-smelling green discharge with mild redness and itching on the genital and dysuria as the major urinary symptom. There was also an associated symptom of fever for 1-2 days that was relieved with Tylenol.
Onset: six weeks ago
Duration: after every episode of sexual intercourse
Characteristics: yellow-green in color, foul smelling
Aggravating factors: regular sexual intercourse
Relieving factors: no sexual activity
Timing: the post-coital bleeding started six weeks while the sore throat started three weeks ago.
Severity: the patient stated that the post coital bleeding increased in frequency with each episode of sexual intercourse making it psychologically taxing band interfering with her sexual life.
Current Medications: None
Allergies: No known drug, food or environmental allergies
PMHx: Up-to-date with all immunizations, no significant PMH
Soc & Substance Hx: S.L. is a 24 year old Caucasian female who works full-time as an administrative assistant. She acknowledges smoking cigarettes ½ pack daily since she was 14 years old and ETOH only over the weekends with 6-8 hard liquor and smoking marijuana. Marijuana is legal in her state. She jogs 3-4 times weekly, wears seatbelts when in the car and occasionally uses sunscreen.
Fam Hx: the patient has two siblings, one sister 35 years old and a brother 30 years old (No PSH or PMH). Her parents, paternal and maternal grandparents are alive and well. There is no history of an underlying familial illness
Mental Hx: patient denies current history of depression or anxiety, homicidal and suicidal ideation or self-harm practices.
OB/GYN History: LMP 05/24/2021, G0P0
- Age of menarche: 13 years old
- LMP: 05/24/2021
- Menstrual Pattern: 28-32day cycle
- Duration of flow: 4 – 6 days
- Amount of flow: Light flow days 1 and 6 & moderate days 2 – 5
- Associated pain with menses: Mild to moderate cramps during menses with mid cycle cramping for 1 -2 days and uses OTC Pamprin
- Intermenstrual bleeding: denies
- Menopause: not applicable
- Current Method of Satisfaction: currently, the patient does not use oral, implants, IUD or injectable contraceptives. Besides, she reports to occasionally use condoms but expresses her disappointment since they cause irritation.
- Previous method, complications and reasons for discontinuation: has previous history of contraception use.
Cervical and Vaginal cytology and Immunization:
- No history of abnormal pap smears: None
- Has never received Gardasil vaccine
- Reports no STI history
- S.L. identifies as a heterosexual
- She reports no current or past sexual assault.
- She has had 13 sexual partners in the past 12 months who have all been male except one in the past year. She engages in sexual intercourse 3 – 4 times weekly involving vaginal, and oral sex.
Review of Systems
General: patient appeared in the office independently. She denied recent chills, fever, night sweats, weight loss or weight gain. She reports a sore throat that has lasted three weeks but denies associated symptoms of a cough, fatigue, or weakness.
HEENT: patient denies dizziness or headache. She denies pain or ringing in the ears. She reports loss of appetite, denies difficulty swallowing, closing or opening the jaw. She denies loss of smell or nasal discharge.
Skin: No rash or itching.
Cardiovascular: patient denies palpitations, swelling in the face, lower and upper extremities, chest pain, or chest discomfort.
Respiratory: the patient denies shortness of breath (SOB), difficulty breathing, cough, wheezing.
Gastrointestinal: the patient reports loss of appetite and lower abdominal pain. She denies vomiting, nausea, and diarrhea.
Genitourinary: the patient reports dysuria, denies hesitancy, frequency, urgency, and burning on urination. She states that urine occasionally has a tinge of blood especially after sexual activity.
Neurological: patient denies memory loss, dizziness, involuntary movement or muscle spasms, LOC, tingling or numbness in the face, lower or upper extremities, and seizures.
Musculoskeletal: No muscle pain, back pain, joint pain, or stiffness.
Hematologic/Lymphatics: patient denies familial or self-history of anemia, she denies spontaneous bleeding or bruising, denies enlarged lymph nodes.
Psychiatric: patient denies history of depression or anxiety.
Allergies: patient denies food, medication or environmental allergies.
General: the patient is AOx4, NAD
VS: Temp: 97.8 °F, BP- 112/64 HR-68 (apical), RR-16, O2 sat-99% RA, Height- 5’6” Weight-118 lbs. (BMI 19.04).
General Appearance: S.L. is AOx4. Generally, she appears to be healthy, well kempt and dressed appropriately for the weather. The vital signs are within normal limits.
HEENT: Neck/Throat: no tracheal deviation/swelling, the thyroid is symmetrical with masses, lumps or goiter. On palpation, there is mild bilateral anterior cervical adenopathy and the throat is reddened.
Respiratory: the lungs are bilaterally clear. The patient has a rhythmic breathing and does not use accessory muscles to breathe. No rhonchi, wheezing, rales, or crackles.
Cardiovascular: No gallops, rubs, or murmurs. Normal heart Sounds S1 and S2 heard. No facial or pedal edema.
Abdominal: the abdomen is soft and non-tender, no lumps or masses felt. Bowel sounds are present and active in all quadrants of the abdomen. She has a normal liver span.
Breast/Chest: symmetrical chest wall noted, bilateral fibrocystic changes and nipple piercings are noted, no dimpling, masses, redness or discharge noted. There is no adenopathy.
- External Genitalia
Vulva/Labia Majora: skin is moist and intact, with mild erythema
Bartholin Gland: soft, no enlargement area is pink and moist
Skene’s: moist and pink
Clitoris: pink, hood skin intact, clitoral piercing noted
- Urethra: slight frothy yellow discharge by the cervix noted
- Bladder: non distended no palpable masses no tenderness upon palpation
- Vagina: foul smelling frothy yellow discharge noted. Normal pattern for hair growth.
- Cervix: friable, there is some petechiae with no cervical motion tenderness.
- Adnexa: no palpable masses, or tenderness present with speculum manipulation
- Rectum: the anus is pink and moist; the sphincter has a good tone, no fissures (patient doesn’t participate in anal sex), no hemorrhoids, masses or discharge. On internal exam, no masses or lumps are palpated. There is no tenderness with the application of pressure on anterior and posterior walls parallel and adjacent to vaginal walls.
Musculoskeletal/Peripheral Vascular: the patient has no edema in the upper or lower extremities. Has a symmetrical development of muscles , equal strength and a good tone and grips. All joints have a FROM with no tenderness, crepitus, edema or inflammation. No deficits in balance and coordination.
Neurologic: the patient is A&O x4. She follows both simple and complex commands. Her memory and perception are intact. Cranial nerves II -XII are grossly intact.
- Pap Smear- Normal with Trichomonads noted
- Throat culture- positive for gonorrhea
- Vaginal culture- positive for chlamydia
- Wet mount- many WBC’s, Trichomonads, positive clue cells, and positive amine (whiff test)
- Hepatitis C-negative
- CAGE Questionnaire-at risk of problem drinking
- Trichomoniasis, Unspecified (A59.0) – Trichomoniasis is a STI caused by the organism Trichomonas vaginalis and the commonest non-viral STI globally. According to Schumann & Plasner (2018), women are more affected as compared to men. Alongside bacterial vaginosis and candidiasis, trichomoniasis is common among women of reproductive age and is often asymptomatic. Patients will report abnormal vaginal discharge, dysuria, dyspareunia, lower abdominal pain, and post coital bleeding. The vaginal discharge may be yellow or green in color, and frothy, purulent, or bloody. On physical exam, the clinician will find a strawberry cervix and lower abdominal tenderness (Schumann & Plasner, 2018). The patient in this case study was sexually active with multiple sexual partners which predisposed her to infection with T. vaginalis. Besides, the physical exam findings of a frothy yellow vaginal discharge, the Pap smear and the wet mount are consistent with trichomoniasis.
- Gonorrhea (A59.4)-gonorrhea is a STI caused by the organism Neisseria gonorrhoeae. Patients present with symptoms of dysuria, mild lower abdominal pain, vaginal discharge, and dyspareunia. In instances where the infection progresses to the PID form, patients will report increased vaginal discharge, fever, dysuria, and cervical motion tenderness (Unemo et al., 2019). On physical exam, patients will have LAP without or with rebound tenderness, vaginal bleeding, and purulent vaginal discharge. Its most common diagnostic test is culture which turned positive for this patient’s case. However, to confirm this diagnosis, a more specific test such as NAAT may be appropriate.
- Bacterial Vaginosis (B96.0) –the common causative organism of bacterial vaginosis is Gardnerella vaginalis. Patients usually present with symptoms of increased mild-moderate vaginal discharge, dyspareunia, and dysuria. One of its most significant predisposing factors that can result in transmission is sexual activity with a new partner or several sexual partners (Agarwal, Soni & Singh, 2019). On physical exam, the labia, cervix and cervical discharge may appear normal. However, patients often have a thin gray homogenous discharge that adheres to the mucosa of the vagina. Key diagnostic findings as it was observed in this patient’s case include; a positive whiff test and positive clue cells.
- Diagnostic Studies
- Pap Smear (annual gyn exam) Z01.419-pending
- Gonorrhea nucleic acid amplification (NAAT) testing-pending-
- Therapeutic interventions:
- Metronidazole PO 500mg BID for seven days. Since there is a high likelihood for co-existence of trichomoniasis with other STIs for this patient, it is advisable to consider empiric treatment of the respective STIs (Gonorrhea and chlamydia).
- Discuss contraception options for this patient.
- Since this patient is at a high risk of AUD/SUD (Alcohol Use Disorder/Substance Use Disorder), prompt referral to therapy for behavioral counselling and further management.
- Educate the patient about STIs, the need to abstain from sex until completion of the pharmacological management with no symptoms.
- Educate on the need to treat sex partners to prevent re-infection and for symptomatic relief
- Educate the patient to avoid alcohol during the entire management period including 24 hours post metronidazole completion.
- Educate the patient about safe sex with alternative if she has an allergy of latex condoms
- Follow-up visits
- Patient to return for follow up in 3 months for retesting
This case was one of the most interesting as it required critical thinking and applying knowledge on how to manage sexually active women of reproductive age seeking care with an underlying diagnosis of more than one STI. For this patient’s case, trichomoniasis was the most probable primary diagnosis. Currently existing research reveals that since trichomoniasis is an STI that affects multiple sites and has a high co-infection rate with other STIs, clinicians must consider empiric treatment of chlamydia and gonorrhea when managing these patients. I also noted that a patient’s socio-economic status is an important factor when diagnosing and managing STIs. For instance, alcohol and drugs use predisposes to risky sexual behavior and subsequent infection with STIs; therefore, when managing patients, it is important to address other contributory factors through education or referral to relevant providers for behavioral counseling and therapy.
Agarwal, M., Soni, R., & Singh, A.(2019). Clinical presentation, diagnosis and management of bacterial vaginosis: a hospital based cross-sectional study. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 9(4), 1555.
Schumann, J. A., & Plasner, S. (2018). Trichomoniasis.
Unemo, M., Seifert, H. S., Hook, E. W., Hawkes, S., Ndowa, F., & Dillon, J. A. R. (2019). Gonorrhoea. Nature Reviews Disease Primers, 5(1), 1-23.
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