Diagnostic Reasoning Case Study
STD Case Study
Martha is a 26-year-old White female who reports vaginal burning for 3 days. She says that she can barely focus on other things because of the burning. She also reports a copious foul-smelling vaginal discharge. Her last pap smear was at age 21 and was negative. She has not received the HPV vaccine series. Martha denies previous episodes and states that she is otherwise healthy. She denies fever, chills, nausea, vomiting, or diarrhea. She is sexually active and has been sexually active with males since age 15. She states that she has had 2 relationships in the past year. Last intercourse was last week. She admits to dyspareunia and burning with urination. She denies the use of vaginal sprays, douches, or powders or the use of new soaps detergent, or clothing. She wears a thong regularly.
Past Medical History:
Tonsillectomy at the age of 7.
Currently on no medications or herbal/vitamin supplements
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Mom with diabetes; Dad COPD; Brother healthy
Martha is a college graduate and lives alone in an apartment. She feels safe and has a good relationship with her boyfriend. Martha works as a teacher and feels financially secure. She does not smoke and denies drug abuse. She drinks socially on the weekends with 1-2 glasses of wine.
Allergies: Seasonal in spring
Vital signs: Martha is afebrile. Her B/P is 110/70. Pulse is 64 and regular. Respirations are 18. She is 5 feet 3 inches tall and weighs 120 lbs.
General: Martha is pleasant and cooperative but anxious about the visit
Cardiac: Regular rate and rhythm without murmurs
Respiratory: Lungs are clear
Abdomen: Soft, non-tender, non-distended, and without organomegaly
Pelvic Exam: Inguinal lymph nodes are without swelling or tenderness; vaginal mucosa is moist, pink, and mildly swollen. There is a fishy odor; copious discharge in the introitus. The cervix is pink and friable. There is a negative chandelier sign. PH is mildly alkaline and wet prep indicates trichomonads.
|Differential 1: Trichomoniasis||Differential 2: Bacterial Vaginosis (BV)
|Differential 3: Chlamydia
|Epidemiology (short synopsis) for each
Who, Where, When
|It is one of the most common STIs in the United States caused byTrichomonas vaginalis. The CDC claims that 5 million new cases of the disease are reported every year, with a higher prevalence among African-Americans living in urban settings(Van Gerwen&Muzny, 2019). It is very common among sexually active females between the age of 14 and 49 years.||It is the most prevalent urogenital condition among women of reproductive age. Approximately 10 to 35% of patients who visit the gynecological wards and obstetric wards present with this disease (Seña et al., 2021). In the united states, the prevalence of BV is 29.9% among women between the age of 14 to 49 years.||It is common among young individuals between the age of 15 to 24 years who are sexually active. According to the CDC, 1 in every 20 sexually active young women have chlamydia (Janssen et al., 2018). Approximately 75% of infected women are asymptomatic.|
|Pertinent positives for each||The diagnosis of this disorder is based on the identification of the parasite Trichomonas vaginalisin the patient’s vaginal fluid, which is positive for this patient(Van Gerwen&Muzny, 2019). Addition indicating factors displayed by the patient supporting the diagnosis include vaginal burning, dysuria, burning with urination, alkaline urine pH, and unusual fishy-smelling vaginal discharge.||The diagnosis of BV is based on the Amsel criteria, which include alkaline vaginal pH, fishy odor of the vaginal discharge, and burning during urination, which is positive for the patient (Paladine& Desai, 2018).||The patient is positive for painful intercourse, unusual vaginal discharge, painful urination(Janssen et al., 2018).|
|Pertinent negatives for each
which require more analytical and creative thinking, are gleaned from the differential diagnosis and function to “rule out” other diagnostic possibilities
|The patient reports no history of nausea, vomiting, chills, fever, or diarrhea. Lat Pap smear test reveals normal results(Seña et al., 2021).
|The patient has no history of homogeneous discharge(Paladine& Desai, 2018). She also displays no identification of clue cells on wet mount microscopy.||The patient presents with no history of white or cloudy discharge, bleeding after sex, painful abdomen or pelvis, and bleeding between periods(Janssen et al., 2018). Lat Pap smear test reveals normal results.
|Patho short summary for each
|The causative parasite T. vaginalis is a motile organism, the size of a white blood cell, with at least 4 flagella. It resides in the urogenital tract lumen. It causes infection by releasing cytotoxic proteins which lead to the destruction of the epithelial lining (Van Gerwen & Muzny, 2019). The vaginal pH normally increases during an infection. The incubation period is approximately 5 to 28 days in women, with symptoms such as foul-smelling discharge, urinary frequency, dysuria, and dyspareunia. Men are usually asymptomatic but may present with urethritis.||BV results from an imbalance in the vaginal flora characterized by a decrease in the number of Lactobacilli promoting the growth of opportunistic bacteria within the vagina(Paladine& Desai, 2018). This infection promotes the access of other vaginal pathogens to the upper genital tract. It also leads to the production of enzymes responsible for reducing the host leukocytes’ ability to fight the infections. It is responsible for the increased endotoxin release stimulating prostaglandin and cytokine production within the vagina.||Chlamydia is an infectious bacteria with two development forms such as reticulate body (RB) and reticulate body (RB)(Janssen et al., 2018).C. trachomatisusually targets thesquamocolumnar epithelial cells of the upper genital tract and the endocervix in women. In both men, it targets the rectum, urethra, and conjunctiva. The bacteria is transmitted via contact with the tissue infected including oral, anal, and vaginal sex. It can also be passed during childbirth to newborns.|
- Primary diagnosis- Trichomoniasis
- Secondary diagnosis- None
Diagnostics: No other tests are needed once the causative parasite has been identified by wet preparation to confirm the primary diagnosis of trichomoniasis(Seña et al., 2021).
Pharmacological: Metronidazole 2g single dose administered orally. Metronidazole is considered highly effective in the management o several protozoal infections such as trichomoniasis(Das, 2021). Single-dose therapy by administering 2g orally is equally effective as prolonged therapy, with 500 mg administered twice daily for 7 days.
Costs: $ 19.99 per 14 tabs at WebMDRx.
Side effects: headache, dizziness, loss of appetite, nausea, vomiting, and a metallic taste in the mouth(Das, 2021).
Drug interactions: alcohol-containing products may interact with the drug, such as cough syrups(Das, 2021).
Patient education: The patient should be advised to take the drug with lots of water. Metronidazole should be taken with a meal or snack(Van Gerwen&Muzny, 2019). Avoid alcohol when taking the medication.
Non-Pharmacological: Engage in protective sex by using a condom and talking with a partner about the infection(Das, 2021).
Follow-up: Report to the clinic in case of persistence or abnormal symptoms after 7 days of therapy(Van Gerwen&Muzny, 2019).
Referrals: The patient might be referred to a gynecologist in case of complications for further evaluation (Das, 2021). This is however not necessary at the moment.
Das, P. (2021). Management and Control of Trichomonas vaginalis Infection: A Recent Study. Highlights on Medicine and Medical Research Vol. 10, 103-106.https://doi.org/10.9734/bpi/hmmr/v10/8897D
Janssen, K. J., Dirks, J. A., Dukers-Muijrers, N. H., Hoebe, C. J., &Wolffs, P. F. (2018). Review of Chlamydia trachomatis viability methods: assessing the clinical diagnostic impact of NAAT positive results. Expert review of molecular diagnostics, 18(8), 739-747.https://doi.org/10.1080/14737159.2018.1498785
Paladine, H. L., & Desai, U. A. (2018). Vaginitis: diagnosis and treatment. American family physician, 97(5), 321-329.
Seña, A. C., Goldstein, L. A., Ramirez, G., Parish, A. J., & McClelland, R. S. (2021). Bacterial Vaginosis and Its Association With Incident Trichomonas vaginalis Infections: A Systematic Review and Meta-Analysis. Sexually transmitted diseases, 48(12), e192.DOI: 10.1097/OLQ.0000000000001537
Van Gerwen, O. T., &Muzny, C. A. (2019). Recent advances in the epidemiology, diagnosis, and management of Trichomonas vaginalis infection. F1000Research, 8.DOI: 10.12688/f1000research.19972.1
Complete case study on the form provided with the subjective and objective data. You will be adding assessment and plan.
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On the diagnostic reasoning table your rationale are the epidemiology, pathology, pertinent positives and negatives. So only references need to be provided for these. The primary diagnosis should be listed as the first differential. Answer all questions and see rubric for grading.
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