Case Study 3:
With any female complaints of abdominal or pelvic pain, the advanced practitioner must modify his or her work-up considerably when compared to working-up a male patient. Female patients are at greater risk for infections or other complications, mostly due to their reproductive system. When evaluating the patient, the complete history must be completed to its fullest. This can enable the practitioners to rule out or rule in many different diagnoses and focus on the priority of care for the patient. The diagnosis and a differential diagnosis can then be made and the practitioner can proceed from there by order of importance. This week, I chose case study 3:
A 21-year-old nulligravida comes to see you concerned about vague lower abdominal pain for two days associated with a yellowish, nonodorous, vaginal discharge. Past history reveals regular menstrual periods and no previous surgeries or significant medical problems. Her last menstrual period was normal and ended two days ago. She had a similar episode about eight months ago for which she did not seek care because of lack of health insurance. She is currently sexually active with one partner and has had two partners in the past year. She is not using any type of contraception. On physical exam, you note a temperature of 38º C, a regular pulse of 100, and a BP of 110/65. Her abdomen is diffusely tender in both lower quadrants. Pelvic exam reveals a yellowish cervical discharge with cervical motion tenderness and a tender fullness in both adnexa.
Differential diagnosis compiled from Schuiling & Likis, 2017.
Ectopic Pregnancy:
An ectopic pregnancy occurs when the fertilized egg attaches itself in a place other than inside the uterus (American Pregnancy Association, 2017). Symptoms associated with an ectopic pregnancy can include sharp, stabbing abdominal pain, vaginal bleeding, and gastrointestinal symptoms(American Pregnancy Association, 2017). In some instances, an ectopic pregnancy can be life-threatening for the patient due to bleeding and emergent surgery may be required.
Pelvic Adhesions:
Pelvic adhesions occur when the body’s process to repair injured tissue takes place. This process of normal healing events may cause some structures in the pelvis to become unintentionally “stuck” to another tissue or structure (Obgyn.net 2011). Treatment can vary from simply managing the symptoms all the way up to requiring surgery. The severity of the adhesions and the effects on the tissue and body will determine the course of action required.
Pelvic Inflammatory Disease (PID):
Schuiling & Likis (2017) define PID as a disease process in the upper female genital tract, usually following menses and includes any combination of endometriosis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. PID can be caused infectious process, therefore, the adolescent population are at greater risk due to a decreased immune process (Schulling & Likis, 2017).
Diagnosis obtained from Schuiling & Likis, 2017.
Diagnosis: PID
The common cause of PID is an infection of the female reproductive organs that occurs when sexually transmitted bacteria spread from the vagina to the uterus, fallopian tubes, or ovaries (Mayo Clinic, 2016).
Treatment:
Common organisms known to cause PID include N. gonorrhea and C. trachomatis as well as aerobic and anaerobic microorganisms including some that are found in vaginal flora (Schulling & Likis, 2017). There are several different combination treatment regimens for PID. Treatment for PID is an oral/intramuscular therapy plan. Ceftriaxone, 250mg IM in a single dose plus Doxycycline 100mg PO, BID for 14 days either with or without Metronidazole 500mg PO BID for 14 days is the first listed treatment plan (Schulling & Likis, 2017). Cefoxitin 2gm IM and probenecid 1gm plus the Doxycycline and Metronidazole therapy or oral third generation cephalosporin with the Doxycycline and Metronidazole therapy can also be used for treatment of PID (Schulling & Likis, 2017).
Prevention:
The Centers for Disease Control and Prevention recommends abstaining from vaginal, anal, or oral sex. If you are in a sexual relationship, then being in a mutual monogamous one, along with proper use of latex condoms is the best way to reduce your risk of contracting PID (Centers for Disease Control and Prevention, 2016.
Reference:
American Pregnancy Association. (2017, March 31). Ectopic Pregnancy. In American Pregnancy Association. Retrieved June 20, 2017, from http://americanpregnancy.org/pregnancy-complications/ectopic-pregnancy/
Centers for Disease Control and Prevention. (2016, May 23). Pelvic Inflammatory Disease (PID) – CDC Fact Sheet. In Centers for Disease Control and Prevention. Retrieved June 20, 2017, from https://www.cdc.gov/std/pid/stdfact-pid.htm
Mayo Clinic. (2016, May 17). Pelvic inflammatory disease (PID) – CDC Fact Sheet. In Mayo Clinic. Retrieved June 20, 2017, from http://www.mayoclinic.org/diseases-conditions/pelvic-inflammatory-disease/home/ovc-20318609
Obgyn.net. (2011, June 21). Pelvic Adhesions. In Obgyn.net. Retrieved June 20, 2017, from http://www.obgyn.net/infertility/pelvic-adhesions
Schuiling, K.D., & Likis, F.E. (2017). Women’s gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett Publishers.
Response # 2 to Tigist Case study # 2
Case study #2 Sexually Transmitted Infections
A 31-year-old African American female is concerned about a white vaginal discharge. She has self-treated in the past with over-the-counter vaginal creams with some success. She has had no relief thus far for this episode.
Most women get concerned and seek care when vulvovaginal symptoms occur such as pain, discharge, odor, itching, irritation, and more: though some vaginal secretions are normal if present without symptoms (Schuiling & Likis, 2017).Vaginal discharge may contain the mucus that comes from the vagina: secretion of clear or whitish fluid from the vagina, which is usually a normal phenomenon (Schuiling & Likis, 2017).It is known that most women have vaginal discharge, particularly those of childbearing age: the amount, consistency, color and smell of discharge vary among women (Schuiling & Likis, 2017). The triggers of increased or altered vaginal discharge can be organized into three groups based on the age group affected: pre-pubertal; reproductive; and post-menopausal. There are organisms in the vagina that protect women by providing an initial line of defense in contradiction of infection from side to side making of lactic acid by lactobacillus species: helps to maintain the PH level 3.5-4.5 in the vagina (Schuiling & Likis, 2017). In this case the patient is presented with complains of a white vaginal discharge that she had self-treated with OTC vaginal cream with no relief.
Differential diagnoses :
Treatment and management plan for the patient
The characteristics of the vaginal discharged, pelvic, and vaginal exam findings are not described well in case study #2, however, the patient be suffering with Vulvovaginal Candidiasis (VVC): is divided as uncomplicated or complicated based om its clinical presentation (Schuiling & Likis, 2017). Patient has not mentioned vaginal itching and burning symptoms. The patient self-treated herself in the past with over-the-counter vaginal creams with some success, but she had no relief so far: some women with recurrent candida infections opt for treatment with over-the-counter (OTC) medications, which generally are highly effective for candidiasis (Arcangelo & Peterson, 2013).
Medications: for recurrent VVC four or more episodes of symptomatic in one year recommended treatment include
Initial therapy of Azole for 7-14 days or fluconazole 150mg by mouth every 3rd day total of 3 doses OR Itraconazole 200mg by mouth daily for three days
Maintenance Therapy for Recurrent VVC
Fluconazole 150mg orally every week for six months OR Itraconazole 100mg-200mg daily for six months OR Miconazole 1200mg vaginal suppository (one) every week x 6 months OR topical treatments intermittently (Schuiling & Likis, 2017). is
Some Alternative Therapies for VVC include 1ts vinegar per quart of water, douche every 5-7 days, 0.25-2% gentian violet few drops in water local or douche application, and more (Schuiling & Likis, 2017).
Strategies to Eduate Patients on the STI
Clinical interventions can be broadly categorized as sexually transmitted infection (STI) management approaches for symptomatic patients, screening (for asymptomatic/symptomatic infections and partner strategies (U.S. Department of Health and Human Services, 2012a) All should be supported by appropriate efforts to educate, counsel and provide the means, such as condoms, to prevent infection: breaking the chain of infection also involves treating as many sexual partners of people with STIs as can be identified (U.S. Department of Health and Human Services, 2012a). as a health care provider, it is important identify the risk factors for STIs and HIV during patient’s health history taking and assessment such as unprotected sex, current and previous SIT, illegal drug use /injection mental illness, age <25 yrs, environment with highly STI and HIV prevalence, sex with multiple sex partners, and more (Schuiling & Likis, 2017). The five P’s (partners, practice, prevention of pregnancy, protection from sexually transmitted infections, and past history of sexually transmitted infection) should be used to screen any women (Schuiling & Likis, 2017). Education include verbal written, individual, and more for woman with STI as soon as possible. Prevention of new infection, treatment/follow-ups adherence, support during treatment (also support when woman discuss with her partner), and education the danger of untreated STI also should be included (Schuiling & Likis, 2017). The use of condom, having only one sexual partner, having a regular checkup for STI, avoiding anal intercourse, avoiding douching, avoiding all sexual activities while on treatment, and more are important information that a clinician should discuss and consult any patient STI/HIV(Schuiling & Likis, 2017).
Patients May use the Resources below on STI
Centers for Disease Control and Prevention. (2013). Incidence, Prevalence, and Cost of Sexually Transmitted Infections in the United States (PDF, 1.6 MB).
Satterwhite, C.L., et al. (2013). Sexually transmitted infections among U.S. women and men: Prevalence and incidence estimates, 2008. Sexually Transmitted Diseases; 40(3): 187–193.
Centers for Disease Control and Prevention. (2017). Syphilis – CDC Fact Sheet.
References
Arcangelo, V. P., & Peterson, A. M. (Eds.). (2013). Pharmacotherapeutics for
advanced practice: A practical approach (3rd ed.). Ambler, PA: Lippincott Williams & Wilkins.
Schuiling, K. D., & Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Burlington,
MA: Jones and Bartlett Publishers.
U.S. Department of Health and Human Services. (2012a). Womenshealth.gov. Retrieved from https://www.womenshealth.gov/a-z-topics/sexually-transmitted-infections
