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1- Discuss the questions that would be important to include when interviewing a patient with this issue.
üElicit history of onset, duration, and location of symptoms.
üNote aggravating and alleviating factors and associated symptomatology.
üQuestion the patient about history of other STIs and sexual habits.
2- Describe the clinical findings that may be present in a patient with this issue.
üDGI lesions, which are painful necrotic pustules on an erythematous base, approximately 1 mm to 2 cm in diameter may be noted in the skin.
üPharynx and oral cavity may show erythema, edema, and lesions such as, red, swollen uvula and pustule vesicles on the soft palate and tonsils.
üAbdominal tenderness, and rebound tenderness.
üWomen only: Discharge and redness present in vaginal walls, and cervical mucopurulent discharge may be noted, next to ectopy, and friability.
üWomen only: Cervical motion tenderness, uterine tenderness, adnexal tenderness, and adnexal masses may be present.
3- Are there any diagnostic studies that should be ordered on this patient? Why?
1- Testing of vaginal, endocervical, urethral (men only), or urine specimens.
üThayer Martin and Genprobe are two of the most commonly used culture media.
üFor persons diagnosed with gonorrhea, testing should also be performed for chlamydia, syphilis, and HIV.
2- During septic joint stage, gonococci can be recovered from the joint by aspiration for culture.
4- List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.
Cervicitis: It is an acute or chronic inflammation of the cervix that is visible to the examiner. Acute cervicitis is predominantly due to infection from bacteria (i.e. C. trachomatis, N. gonorrhoeae, mycoplasma, Ureaplasma) or viruses (i.e., HSV 2, HPV, T. vaginalis). Chronic cervicitis is primarily due to trauma occurring during childbirth or instrumentation, infection, and/or presence of foreign bodies (Cash & Glass, 2014). Predisposing Factors include: vaginal delivery, cervical procedures, IUD, and STIs. Common complaints include: copious mucopurulent vaginal discharge and postcoital bleeding (Cash & Glass, 2014).
Gonorrhea: It primarily involves mucocutaneous surfaces of the genitourinary tract, pharynx, conjunctiva, and anus. It attacks the urine canal of both sexes and can develop in the mouth, anus, and throat. The frequent area for infection in women is the cervix. In both sexes, this can injure the joints, brain, and heart valves (Mayo Clinic, 2015).
1- Urinary Tract Infection (UTI): Common Complaints include: burning on urination, frequency, cloudy or bloody urine, urgency, suprapubic pain, fever, CVA tenderness, and/or hematuria (Cash & Glass, 2014). The urine culture should show a positive culture. In this case the urine culture showed no bacterial growth.
2- PID: An abrupt onset of acute lower abdominal pain following menses has been considered the characteristic presenting symptom of PID, but symptoms of this infection can also be very mild and nonspecific. Frequently reported symptoms include abdominal, pelvic, and low back pain; abnormal vaginal discharge; intermenstrual or postcoital bleeding; fever; nausea and vomiting; and urinary frequency. Pelvic pain is usually exacerbated by the Valsalva maneuver, intercourse, or movement (Schuiling & Likis, 2017).
3- Bacterial Vaginosis: occurs when there is an imbalance between bacteria that are normally present only in small amounts and normal vaginal lactobacilli bacteria. This condition can occur if a woman douches frequently or has new or multiple sexual partners. The most common sign of a bacterial vaginosis infection is a thin, milky discharge that is often described as having a “fishy” odor. Diagnostic tests include: a positive whiff test and a vaginal PH greater than 4.5 (Cash & Glass, 2014). In this case the whiff test was negative and the vagina PH was 4.0 less than 4.5.
5- Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.
Recommendations for treatment:
üCeftriaxone 250 mg by intramuscular (IM) injection of a single dose, or
üCefixime 400 mg by mouth in a single dose or
üSingle dose injectable cephalosporin plus azithromycin 1 g orally single dose or
üdoxycycline 100 mg orally twice daily for 7 days
üFor patients with severe allergy to cephalosporins, the CDC recommends azithromycin 2 g dose orally. As per the CDC quinolones no longer be used for treatment of gonorrhea due to the increased bacterial resistance.
All individuals should be closely monitored for treatment failure and treatment of all sexual partners within the past 60 days of diagnosis should be reinforced. Refer the patient to an infectious disease specialist if treatment with the recommended dosage fails and patient noncompliance and reexposure have been ruled out (Cash & Glass, 2014).
Cash, J. C. & Glass, Ch. A. (2014). Family Practice Guidelines, 3rd Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/boo…
Mayo Clinic. (2015). STD symptoms: Common STDs and their symptoms. Retrieved from: http://www.mayoclinic.org/diseases-conditions/sexu…
Schuiling, K.D & Likis, F.E. (2017). Women’s Gynecologic Health, 3rd Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/boo…