NRNP 6552 Advanced Nurse Practice in Reproductive Health Care
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.
Case Study Discussion: Common Gynecologic Conditions, Part 1
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.
Photo Credit: Teodor Lazarev / Adobe Stock
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.
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To prepare:
- 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. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your FOCUSED SOAP note. This information will help you develop your differential diagnosis and additional questions
By Day 3
Please POST your FOCUSED SOAP NOTE and 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. 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.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Advanced Nurse Practice in Reproductive Health Care
Focused SOAP note
Patient initials: S.L Age: 24 Sex: F Race: Caucasian DOB: 2/4/1998
Subjective
CC: “Post-coital bleeding”
HPI: The Patient, a 24-year-old Caucasian female, presented to the clinic for regular care with the chief complaint of post-coital bleeding that had been plaguing her for the past six weeks. She also mentioned that she suffered a sore throat for three weeks and a fever that she was able to manage with Tylenol 500mg. The patient also stated that she has a 4-6 day menstrual cycle with cramps; however, she frequently relies on OTC Pamprin to alleviate her discomfort. She also reported using three tampons every day during her period.
Current medication: Currently, the patient is not under any prescription. Reported taking Tylenol 500mg 2tab prn some days back to relieve fever and has been using otc Pamprin 2tab prn for her menstrual pain.
Allergies: NKDA
PMHx / SHx: no medical or surgical history
Immunization status: not reported.
Soc & substance Hx: The patient is a full-time administrative assistant who likes her work. Her social background is renowned for her cigarette smoking, that she reported using 12 packs per day since the age of 14. She also claimed to take ETOH only on weekends and consume 6-8 strong liquors each day. The patient also takes marijuana. She jogs three to four times each week, wears her seatbelt when driving, and applies sunscreen on occasion.
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Reproductive Hx: The patient’s menstruation started when she was 13 years old. Her menses follow a 28-32 menstrual cycle, last for 4 to 6 days, and is accompanied by menstrual cramps. She reported using a maximum of three tampons daily during her menses.
Family history: Non-contributory
ROS:
General: The patient reported experiencing a fever that lasted for one to two days. She denies chills, night sweats, and weight changes.
HEENT: No vision and hearing problem was reported.
Skin: No bruising, or skin changes reported.
CVS: No chest pain or changes in heartbeat reported.
Respiratory system: No wheezing, dyspnea or productive cough was reported.
GIT: No changes in appetite, nausea, or vomiting were reported.
Neurologic: No cases of headache or seizure were reported.
GUT: The patient reported having post-coital bleeding in the past six weeks.
O
Physical exam
Vital signs: TP 97.8 Ht 5’ 6” Wt. 118 , BMI 19.04, BP 112/64 P 68
HEENT: Normocephalic and atraumatic. Hair is of normal texture and evenly distributed. EOM is intact, PERRLA, External ear is non-tender. Anterior cervical adenopathy with a reddened throat was noted.
Lungs: clear to auscultation
CV: regular sinus rhythms without murmur or gallop
- Abd: soft, +BS, non-tender, liver normal,
Breast: soft, fibrocystic changes bilaterally, no masses, dimpling or discharge, no adenopathy, and bilateral nipple piercings
- VVBSU: wnl, slight frothy yellow discharge by the cervix, clitoral piercing noted
Cervix: friable, some petechia no cervical motion tenderness.
Uterus: mid-mobile, non-tender
Adnexa: without masses or tenderness
Extremities: full rom, skin clear, no edema, reflexes 1+.
Neurological: CN II-12 grossly intact.
Perineum: intact, no lesions or warts
Rectum: normal sphincter tone, guac negative
Additional questions
The questions I will ask the patient to dig deeper into diagnoses include:
- What is your sexual orientation? Are you heterosexual, homosexual, or bisexual?
- How many sexual partners have you had in the last few months?
- What form of contraception have you been using?
- When was your latest Pap smear/pelvic examination conducted?
- Have you ever suffered from any sexually transmitted infection?
- Have you ever felt irritated or burned when urinating?
- Does your vaginal discharge have a strange odor?
- Have you seen any sores in your vaginal area? or anyplace else in your body?
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These questions will help provide primary diagnoses. To determine the underlying cause of a sickness, the healthcare professional must be aware of any heinous conduct exhibited by the patient. Vaginal fluid features and morphology are very suggestive of a distinct pathogenic disease.
Primary diagnoses
Trichomoniasis
This is a sexually transmitted infection caused by the motile parasite protozoa Trichomonas vaginalis. In women, this condition is marked by aberrant odor, vulvovaginal burning and itching, pain during sexual intercourse, lower stomach pain, and post-coital bleeding, rendering it the most likely diagnosis. According to Huneeus et al. (2018), T vaginalis infection is connected with a high risk of infection with other STIs such as gonorrhea, Chlamydia, and HIV, hence further testing is recommended.
Diagnostics test and treatment
The nucleic acid amplification test (NAAT) will be much more instrumental in detecting chlamydia and gonorrhea infection in the female reproductive tract (Van Der Pol et al., 2021). This can be accomplished using vaginal swabs or a urine sample. Other tests, such as an HIV test and a PH test for Trichomoniasis detection, are also recommended.
Based on the primary diagnosis, metronidazole 500mg Po x 1/52 is highly recommended (Muzny et al., 2022). She should be instructed not to drink alcohol for 24 hours after taking the medication and for three days after finishing the course since the two can trigger a disulfiram-like response when combined. She should be counseled to use condoms and should bring her sexual partner with her for therapy.
References
Huneeus, A., Schilling, A., & Fernandez, M. I. (2018). Prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis infection in Chilean adolescents and young adults. Journal of Pediatric and Adolescent Gynecology, 31(4), 411-415. https://doi.org/10.1016/j.jpag.2018.01.003
Muzny, C. A., Mena, L. A., Lillis, R. A., Schmidt, N., Martin, D. H., & Kissinger, P. (2022). A Comparison of Single-Dose Versus Multidose Metronidazole by Select Clinical Factors for the Treatment of Trichomonas vaginalis in women. Sexually Transmitted Diseases, 49(3), 231-236. https://doi.org/10.1097/OLQ.0000000000001574
Van Der Pol, B., & Gaydos, C. A. (2021). A profile of the binx health io® molecular point-of-care test for chlamydia and gonorrhea in women and men. Expert Review of Molecular Diagnostics, 21(9), 861-868. https://doi.org/10.1080/14737159.2021.1952074