Patient Information:

Initials: A. J. Age: 38, Sex: Female, Race: Caucasian

CC (principal complaint): “Since four days ago, I have been experiencing a burning pain in my lower abdomen, urinating more frequently, and feeling the need to urinate immediately.”

HPI: A.J., a 38-year-old white female, presented to the clinic with four days of lower abdominal discomfort. The pain is located in the suprapubic region, began suddenly, and has been progressively escalating since its onset. Typically, it is predominantly searing and sometimes cramping. It gets worse as the bladder fills and gets better as she voids. The discomfort is accompanied by an urgent need to urinate. It can occur at any time of day or night, with no specific timing. Occasionally, the pain is accompanied by urinary distress, and it can also be felt during sexual penetration. Due to frequent urination, she reports that the sensation has caused her stress and occasionally interferes with her social and professional functioning. The intensity of the agony is a 7 out of 10. She has been treated multiple times for UTIs, but the symptoms persist. However, no blood is present in her urine.

Current Treatments: Currently, she is consuming one vitamin D supplement tablet daily. This has been her go-to for the previous twelve months. She does not take any additional over the counter or homeopathic medicines.

Allergies: The patient developed angioedema of the perioral mucosa in response to Vasotec (Enalapril) in the past. There have been no additional reports of adverse drug, dietary, or environmental reactions.

PMHx: The patient has been immunized according to the specifications. Her last injection of tetanus toxoid occurred six years ago. She has received multiple treatments for UTIs in the past.

Soc & Sub Hx: The patient is a high school teacher. She is now unattached. She has three children who are alive and thriving. Currently, they are living with their father. She appreciates cooking as well as dancing. She vapes on occasion, but she hasn’t smoked tobacco in two years. She smoked a daily quarter carton for fifteen years prior to quitting. In the past decade, she has consumed approximately ten units of alcohol per week. She wears a seatbelt while driving and resides in a safe neighborhood. She dispatches texts and makes phone calls while driving on occasion. She does not jog or work out at the gym, and her home lacks smoke detectors. Her network of support includes her mother and two siblings.

Family Hx: Is unremarkable for hypertension, diabetes, chronic pelvic syndromes, and malignancies. His father was killed in an automobile accident. The mother is alive and devoid of major comorbidities. Her siblings and offspring have no complaints.

Sirgical Hx: In her most recent delivery, which occurred seven years ago, she underwent a Caesarean section. There have been no subsequent surgical procedures performed on her.

Psychiatric Hx: She has developed anxiety in the past year, but it has not been diagnosed. She has no history of depression, suicidal thoughts, or murderous thoughts.

Violence Hx: She reports that she is secure from physical assault or sexual exploitation in her community or workplace.

Reproductive Hx: She has the genetic code G3P3L2. Her last normal period occurred on March 6 of this year. She currently uses a copper intrauterine device to prevent pregnancy. She favors intravaginal interactions with males. She has no sexual complaints or concerns at this time.

ROS:

GENERAL: There have been no reports of her experiencing weight loss, fever, or shivers.

HEENT: Eyes: Eyes: Her vision does not seem distorted or duplicated. Her sclera did not have any yellowing. There is no discomfort or hearing loss. There was no nasal congestion or sneeze. There is no throat discomfort present.

SKIN: The epidermis is free of rashes and excessive itching.

CARDIOVASCULAR: No reports of chest pain, edema, palpitations, paroxysmal nocturnal dyspnea, or chest pain were received.

RESPIRATORY: She does not suffer from breathlessness, sputum, or congestion.

GASTROINTESTINAL: She suffers from neither anorexia nor nausea. There is no vomiting or diarrhea present. She reports abdominal discomfort.

NEUROLOGICAL: She has no headaches, paralysis, syncope, ataxia, tingling in the legs and extremities, or numbness. No gastrointestinal or urinary regulation abnormalities.

MUSCULOSKELETAL: She does not report any muscle discomfort, tetany, or edema.

HEMATOLOGICAL: She is neither anemic nor prone to excessive bruising or hemorrhaging.

LYMPHATICS: She denies having enlarged lymph nodes and has no history of splenectomy.

PSYCHIATRIC: Indicates anxiety but rules out depression.

ENDOCRINE: She reports no excessive perspiration, intolerance to cold or heat, excessive thirst, or tendency to consume.

GENITOURINARY/REPRODUCTIVE: She occasionally experiences scorching urination along with urgency, frequency, and incomplete emptying. Her LMP was from 6 June 2023. Periods are not burdensome. Experiences dyspareunia on sexual engagement. No discharge or hemorrhaging. No unusual odor or hue.

ALLERGIES: She has no previous history of eczema, rhinitis, asthmatic attacks, or urticaria.

Physical Exam:

Vitals:

RR: 17

BP: 129/81 Oxygen Sat: 99%

Pulse rate: 76

Temperature: 98.9

Weight: 165 lb Height; 5’5 BMI: 27.5

General: The patient is a young woman in average health and with a sound nutritional status.

HEENT: Her cranium is spherical, and her thick, dark hair is evenly distributed across the scalp. No tender regions or bulk. Eyes are oval in shape and free of conjunctival injection, scleral discoloration, and periorbital edema. Her visual acuity and color perception have not diminished. The pinna is in its typical position, with both canals accessible. There are no indicators of perforation on the tympanic membrane, which is gray in color. No blood or mucus is oozing from the ears. Hearing is reliable. Nose: The nasal passageway is devoid of congestion and watery secretions. The nasal mucosa is pink, hydrated, and hairy. No mucosal discolorations or ulcerations are present in the pharynx or mouth. The teeth are aligned, spotless, and appropriately aligned. This tongue is straight and rosy.

Skin: The epidermis is warm and devoid of any eczema or other lesions.

Neck: Trachea is centered, and there are no masses or enlarged lymph nodes present in the neck.

Chest and lungs: There are no visible deformities, lesions, or abnormalities in distended vessels in the chest and lungs. Ventilation causes symmetrical thoracic motion. There are no masses, tenderness, anomalous coloration, lumps, or discharge in the breasts, but vesicular sounds and zones of resonant lung tissue were detected in the lungs.

Heart and peripherals: Absence of precordium hyperactivity in the heart and periphery. The peak rhythm does not shift. Both S1 and S2 are obvious. In three seconds, the capillaries are replenished.

Abdomen: The abdominal region is not fully expanded. We did not observe any aberrant vessel dilation, scarring, or discoloration. There are eight gastrointestinal sounds per minute with no variation in loudness. Tympanicity is measured in all four quadrants. There is no visible organ enlargement, but the suprapubic region is tender.

Genitals: The vulva has a normal anatomy and female-typical hair distribution. There were no warts, ulcers, or lesions observed, nor was there any discharge or odor. The cervix has a mauve hue. Inactivity causes cervical discomfort.

Rectal: There are no wounds, ulcers, or lesions evident in the rectal region. There are no sinuses that discharge pus or blood. No mass was found.

Musculoskeletal: adequate muscle strength, mass, and tone. No compassion. Brisk reflexes.

Neurologically, the patient is alert and conscious, with gross cranial and peripheral nerve functions preserved. No deficits in neurological functioning exist.

Psychiatric: She is calm, with minimal anxiety. There were no observations of catatonia or other anomalous movements. There are no compulsions, delusions, or hallucinations in her disposition. Her memory and perception are both sufficient.

Diagnostic Results: An infection of the urinary tract was confirmed by a positive urinalysis, which included a urine dipstick, culture, microscopy, and sensitivity. Leukocyte esterase test results were also positive. Urine culture is not always necessary for uncomplicated UTIs, but it is essential in cases of diabetes and its complications. A urine pregnancy test was negative. Random blood glucose and HbA1c levels were within the reference ranges for diabetes. In addition, a complete blood count was conducted to identify white cell count and hemoglobin abnormalities (Kolman, 2019). In addition, it is necessary to conduct a sexual medical examination, including a cervical exam and specimens for chlamydia and herpes. In this case, urodynamic studies to determine the integrity of the lower urinary tract are beneficial because the patient has a history of recurrent UTIs. Cystoscopy performed to detect bladder cancer or other structural abnormalities revealed the absence of any significant pathologies. Interstitial cystitis is indicated by the presence of Hunner’s ulcers (Lelievan der Zande et al., 2020). The same holds true for reactive hemorrhages. Transvaginal ultrasonography can detect cysts, adenomyosis, and masses, such as hydrosalpinx, which is indicative of PID.

Primary and Differential Diagnoses

UTIs: Are a prevalent condition that can affect the kidneys, bladder, ureters, and urethra. Females are more susceptible to UTIs than males due to the anatomy of the female urinary tract. The proximity of the anus and vagina to the urethra increases the likelihood that bacteria will enter the urinary tract (Kwok et al., 2022). Escherichia coli, which occurs naturally in the colon, is the most prevalent cause of urinary tract infections. Sexual contact, inadequate hygiene, certain health conditions such as diabetes, invasive urinary procedures, and a weakened immune system can also contribute to UTIs (Lelievan der Zande et al., 2021). Repeated UTIs in A.J. may be due to inadequate treatment of her previous infections, reinfection by the same organism, or a structural abnormality in her urinary tract. To determine the underlying cause of her symptoms and administer the appropriate treatment, it will be necessary to conduct additional diagnostic tests. Typically, urinalysis results are positive.

Interstitial Cystitis: A non-infectious inflammatory disorder of the urinary tract. Patients typically experience supply pubic discomfort and an urgent need to urinate. The sensation is intensified when the bladder is filled and disappears after urination (Kolman, 2019). As a result, the patient urinates more often. There is no particular timing for the pain, and it is often accompanied by other complaints, such as urinary distress and painful sexual relations (Osman et al., 2021). These symptoms have a significant impact on an individual’s psychological, social, and emotional health. The patient exhibits an abundance of these symptoms.

Pyelonephritis is a type of urinary tract infection characterized by inflammation of the kidney and renal pelvis, the funnel-shaped portion of the kidney where urine accumulates before entering the ureter. Pyelonephritis is commonly caused by a bacterial infection, most frequently Escherichia coli, and can be the result of an ascending bladder infection or a bloodborne infection. Pyelonephritis is distinguished by fever, shivers, flank pain, abdominal pain, nausea and vomiting, as well as frequent urination (Osman et al., 2021). Sepsis is a life-threatening condition induced by widespread inflammation caused by the immune system’s response to an infection in severe cases. Pyelonephritis is typically diagnosed through a physical examination, a review of the patient’s medical history, and laboratory testing, such as a urine culture and blood tests. Imaging techniques, such as CT scans or ultrasounds, may also be used to evaluate the kidneys.

Management Plan

In addition to urinalysis and urine culture, additional diagnostic procedures may include ultrasonography and computed tomography scans. If the symptoms persist, a urologist is referred for further evaluation and treatment, and a gynecologist is referred if the symptoms are associated with sexual activity or pelvic inflammatory disease. Therapeutic interventions include antibiotics based on urine culture and sensitivity, NSAIDs or other analgesics, bladder analgesics or antispasmodics, and promoting adequate hydration and urination (Kwok et al., 2022). Education consists of proper bladder evacuation techniques, proper hygiene practices, completing the full course of antibiotics, and lifestyle modification. A follow-up appointment should be scheduled in 3 months to evaluate any recurrent UTIs or complications, and within 7 to 10 days to assess the patient’s response to treatment. Antibiotics based on the urine culture and sensitivity, nonsteroidal anti-inflammatory drugs (NSAIDs) or other analgesics, and bladder analgesics or antispasmodics are administered according to the demands of the individual patient. A specific antibiotic may be 160 mg trimethoprim/800 mg sulfamethoxazole for five days. For the treatment of recurrent urinary tract infections, improving personal hygiene, using vitamin C as a urinary acidifier, and taking extra precautions after sexual contact are suggested (Abou Heidar et al., 2019). In addition to probiotics derived from cranberries, for which there is some evidence of efficacy, prophylactic antimicrobials or antiseptics such as nitrofurantoin and methenamine may also be employed. There is insufficient evidence to support the use of D-mannose as a preventative agent (Lelievan der Zande et al., 2021). Six to twelve months is the typical duration of prophylactic treatment, with limited data available for extended durations. Beneficial for postmenopausal women with atrophic vaginitis who administer estrogen vaginal cream twice weekly (Osman et al., 2021). The treatment chosen will depend on patient-specific factors, which should be discussed with the healthcare provider.

Reflection: Standard treatment for UTIs is the administration of antibiotics based on urine culture and sensitivity; the medication chosen will depend on the outcomes of the tests. Prophylactic antibiotics or antiseptics, cranberry supplements, and vaginal estrogen ointment may also be appropriate for the treatment of recurrent UTIs. This case taught me the significance of taking the patient’s unique needs and medical history into account when devising a treatment plan. In addition to emphasizing the importance of completing the full course of antibiotics to ensure that the infection is completely treated, it is crucial to educate the patient on appropriate hygiene practices and lifestyle changes that may prevent future UTIs (Kwok et al., 202). If any aspects of the management plan were ambiguous or not well supported by the evidence, I would consider consulting additional resources or seeking the advice of other healthcare professionals. This case demonstrates the significance of an all-encompassing and individualized UTI management strategy. Proper sanitation practices are essential for preventing urinary tract infections (UTIs). It is essential to routinely clean the genital area, wipe from front to back after using the restroom, and avoid using scented soaps, powders, or sprays that can irritate the urinary tract (Abou Heidar et al., 2019). Additionally, urinating prior to and after sexual activity can help flush pathogens from the urinary tract and reduce the likelihood of infection. In order to prevent UTIs, hydration is essential because it helps flush pathogens from the urinary tract. Consuming copious quantities of water and avoiding beverages that can irritate the bladder, such as coffee and alcohol, can reduce the risk of infection. As the fruit contains compounds that prevent bacteria from adhering to the urinary tract, there is some evidence that consuming cranberry supplements or imbibing cranberry juice can prevent urinary tract infections (UTIs). Individuals with recurrent UTIs may benefit from prophylactic antibiotics or antiseptics, in addition to lifestyle modifications such as taking vitamin C supplements, taking additional precautions after sexual contact, and applying vaginal estrogen cream in postmenopausal women with atrophic vaginitis.

References

Abou Heidar, N. F., Degheili, J. A., Yacoubian, A. A., & Khauli, R. B. (2019). Management of urinary tract infection in women: A practical approach for everyday practice. Urology annals, 11(4), 339. https://doi.org/10.4103%2FUA.UA_104_19

Links to an external site.

Kolman, K. B. (2019). Cystitis and pyelonephritis: diagnosis, treatment, and prevention. Primary Care: Clinics in Office Practice, 46(2), 191-202. https://doi.org/10.1016/j.pop.2019.01.001

Links to an external site.

Kwok, M., McGeorge, S., Mayer‐Coverdale, J., Graves, B., Paterson, D. L., Harris, P. N., … & Roberts, M. J. (2022). Guideline of guidelines: management of recurrent urinary tract infections in women. BJU international, 130, 11-22. https://doi.org/10.1111/bju.15756

Links to an external site.

Lelie‐van der Zande, R., Koster, E. S., Teichert, M., & Bouvy, M. L. (2021). Womens’ self‐management skills for prevention and treatment of recurring urinary tract infection. International Journal of Clinical Practice, 75(8), e14289. https://doi.org/10.1111/ijcp.14289

Links to an external site.

Osman, N. I., Bratt, D. G., Downey, A. P., Esperto, F., Inman, R. D., & Chapple, C. R. (2021). A systematic review of surgical interventions for the treatment of bladder pain syndrome/interstitial cystitis. European urology focus, 7(4), 877-885. https://doi.org/10.1016/j.euf.2020.02.014

Initial Post

Patient Information:

SC, 22 yo, Female, Caucasian

CC: “It burns when I pee and I have discharge”

HPI: SC is a 22 yo Caucasian female who presents to the clinic with complaints of “intense and painful” burning urination and vaginal discharge. She had unprotected intercourse approximately a week and a half ago with a male she met at a party. Vaginal discharge started 5 days ago and the painful urination started 3 days ago. She notices the discharge daily in small to moderate amounts. Urine pain occurs only during urinary flow and stops after it is completed. She says the vaginal discharge is thin and clear to white in color. Painful urination is described as a burning/stinging sensation. She denies fever, back/flank pain, vaginal odor, or bleeding. She has not checked for vaginal lesions but thinks the left labia is a little “puffier” than normal. Pain is non-radiating. She has been having some mild pelvic discomfort that is described as pressure and tingling. She has been taking Tylenol which has provided her with some relief. She rates her pain a 3 but when she has to urinate, the pain is 9/10.

Current Medications:

Tylenol- 1,000 mg PRN pain

Yaz drospirenone 3 mg / ethinyl estradiol 0.02 mg (DS)- take one by mouth daily

Immunizations:

Childhood immunizations UTD

Tdap- 2019

Allergies:No know medication, latex, or environmental allergies

PMHx: Denies

Soc & Substance Hx: Patient is a full-time student at a local university. She lives on campus. She reports alcohol use mostly on the weekends. 5 or more alcoholic drinks on a night when she is out with her friends or at a party. Occasional marijuana use. Denies tobacco or vaping.

Fam Hx: Non-contributory

Surgical Hx:Denies

Reproductive Hx: G00000. Age of menarche 12. LMP: 6/1/23- last 4-5 days, heavy flow days 1-2, moderate to light days 2-5. Identifies as heterosexual. Not in a relationship. Sexually active- no consistent partner. Daily birth control. Occasional barrier protection use. Last pap smear 2020- normal. Denies hx of STI

ROS

GENERAL: No Fatigue, weight loss, fever, or chills

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: Swelling to left labia. Denies itching

CARDIOVASCULAR: Denies chest pain/pressure/discomfort. No
palpitations or edema.

RESPIRATORY: Denies cough, SOA, or sneezing

GASTROINTESTINAL: Denies abdominal pain, anorexia, nausea, vomiting, or diarrhea

NEUROLOGICAL: Denies headache, dizziness, numbness, or tingling in the extremities. No change in bowel or bladder control

MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, or stiffness

HEMATOLOGIC: Denies anemia, bleeding, or bruising

LYMPHATICS: Denies enlarged nodes. No history of splenectomy

PSYCHIATRIC: Denies depression or anxiety

ENDOCRINOLOGIC: Denies sweating. no cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY/REPRODUCTIVE: “intense and painful” burning on urination. Left labia swelling. Clear to white in color vaginal discharge. Pelvic pressure and “tingle” sensation. LMP: 6/1/23. Denies urinary urgency or frequency

ALLERGIES: No history of asthma, hives, eczema, or rhinitis

BP: 120/84 sitting/ Temp: 98.8 oral/ pulse 78/ O2 100% RA/ height 5’7” and weight 120 lbs. BMI 18.8

CARDIOVASCULAR: S1 S2 on auscultation, RRR. No carotid bruits. No murmurs, gallops, or rubs. 2+ Radial and pedal pulses bilaterally

RESPIRATORY: Equal chest rise and fall. No nasal flaring. Normal respiratory effort. No rales/crackers/rhonchi

GASTROINTESTINAL: BS present x 4. Abdomen is soft, symmetric, non-tender w/o distention, no masses

GENITOURINARY/REPRODUCTIVE: Two circular vesicular lesions to the left labia minora at 1600. Lesions tender on palpation. Thin white vaginal discharge visualized. Cervix: firm, smooth, parous, w/o CMT. Uterus: mid-mobile non-tender. Adnexa: without masses or tenderness

LYMPHATIC: Bilateral inguinal nodes palpated

Differential diagnosis- Herpes Simplex Virus (HSV)

Possible diagnosis

Gonorrhea

Chlamydia

Furunculosis

HSV is a viral infection spread by contact. There is no cure for the virus but it is treatable. HSV is categorized as Type 1 (HSV-1) which spreads by oral contact and causes cold sores (Herpes Simplex Virus, 2023). Type 2 (HSV-2) is a sexually transmitted infection that causes sores to the genitals (Herpes Simplex Virus, 2023). According to Omarova et al. (2022), the patient’s with HSV can present with painful lesions around the genitals, dysuria, discharge, or swollen lymph nodes. I believe the diagnosis of HSV is the most important because it does not always present with physical symptoms yet is still transmissible. Additionally, in women who have HSV-2, most commonly during delivery, the virus can pass to the infant leading to a dangerous condition called neonatal herpes (Omarova et al., 2022).

In conducting my assessment, a complete and thorough history of present illness would be a priority. Obtaining as much detail as possible helps determine a potential diagnosis and necessary diagnostic testing. It is also important to visually inspect the pelvis for lesions, perform a pelvic examination, pap smear, and collect a type-specific viral culture to determine if the infection is HSV-1 or HSV-2.

Testing:

Urine pregnancy- to rule out pregnancy

Pelvic exam- to visualize any lesions, discharge, or abnormalities. Visualize the cervical OS, check for CMT

HSV NAAT and PCR amplicons – to test for HSV and identify if the infection is caused by HSV-1 or HSV-2

Nucleic acid amplification tests (NAATs)- to test for Chlamydia, Gonorrhea, and

Trichomoniasis

HIV NAT- to check for HIV transmission- the patient had unprotected sex with a male whose sexual history is unknown. This test can detect the presence of HIV 10-33 days after exposure (Centers for Disease Control and Prevention, 2022).

KOH wet mount- to check for Yeast and BV. Whiff test for BV

Treatment recommendations:

Initial outbreak: Valacyclovir – 1g orally twice a day for 10 days

Recurrent management- Acyclovir- 800 mg twice daily for 5 days

Suppressive management- Valacyclovir 500 mg orally once daily

The patient had unprotected intercourse with someone whose sexual history is unknown. I would recommend prophylactically treating the patient for Gonorrhea, Chlamydia, and Trichomonas. Due to the patient’s age and risk of medication non-compliance, I would prescribe Azithromycin 1 g orally for one dose to treat possible Chlamydia and Trichomonas (Van et al., 2023). To treat the patient for Gonorrhea, I would order Ceftriaxone 500mg IM for one dose (Van et al., 2023). It has been my experience that young adults, especially those on their parent’s health insurance, will delay seeking care because they do not want their parents to know they are sexually active and or have contracted an STI. Often these patients decline to use their insurance and ask to pay out of pocket for their healthcare visit.

References

Centers for Disease Control and Prevention. (2022, June 22). Understanding the HIV Window Period | Testing | HIV Basics | HIV/AIDS | CDC. Www.cdc.gov. https://www.cdc.gov/hiv/basics/hiv-testing/hiv-window-period.html

Herpes simplex virus. (2023, April 5). Www.who.int. https://www.who.int/news-room/fact-sheets/detail/herpes-simplex-virus#:~:text=Herpes%20simplex%20virus%20(HSV)%2C

Omarova, S., Cannon, A., Weiss, W., Bruccoleri, A., & Puccio, J. (2022). Genital Herpes Simplex Virus-An Updated Review. Advances in Pediatrics, 69(1), 149–162. https://doi.org/10.1016/j.yapd.2022.03.010

Van, C. E., Malleson, S., & Grennan, T. (2023). A practical approach to the diagnosis and management of chlamydia and gonorrhea. CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 195(24), E844–E849. https://doi.org/10.1503/cmaj.221849

irst Colleague Response -Week 5

Case Study Discussion for Common Gynecologic Conditions

Hello Needra. Similar to your patient’s complaints and diagnosis, I also diagnosed my first case of HSV-2 this week. Genital herpes is one of the STDs that can be made through physical examination and observation of the genital lesions without having to perform validity testing (Roett, 2020). Because cultures confirm what is presumed and eliminate many of the differential diagnoses, they leave patients with little doubt about their diagnosis. In many instances, additional testing to exclude other possibilities, including a clinically diagnosed HSV-2, is warranted.

For your patient, I would suggest syphilis serology be added to your list of testing. Syphilis is a closely related sexually transmitted disease that should be included as a differential diagnosis. In fact, a single or multiple chancres of primary syphilis to the genitalia could resemble the lesions associated with HSV-2. The description syphilis chancres are described as painless ulcers with a “hard edge and clean, yellow base.” (Hollier, 2021, p. 933). The two lesions on your patient’s labia could still be related to a Treponema pallidum infection. The RPR test can be added to her lab collection to determine if those lesions are herpetic or syphilitic.

In closing, I would like to warn against treating patients prophylactically with antibiotics because of the rise in drug resistance. May et al. (2021) advised clinicians to improve antibiotic prescribing for the prevention of drug resistance, adverse effects, and the associated cost of overprescribing. Patients that have the potential to have more than one STD should wait on confirmation for treatment and be treated accordingly. Thank you for the opportunity to add my thoughts to your case for this discussion.

References

Hollier, A. (2021). Clinical guidelines in primary care (4th ed.). Advanced Practice Education Associates.

May, A., Hester, A., Quairoli, K., Wong, J. R., & Kandiah, S. (2021). Impact of clinical decision support on azithromycin prescribing in primary care clinics. Journal of General Internal Medicine, 36(8), 2267-2273. https://doi.org/10.1007/s11606-020-06546-y

Links to an external site.

Roett, M. A. (2020). Genital ulcers: Differential diagnosis and management. American Family Physician, 101(6), 355–361. https://search.ebscohost.com/login.aspx?direct=true&AuthType=shib&db=edb&AN=143623851&site=eds-live&scope=site Links to an external site..

Hello Needra,

Thank you for sharing the patient’s case and starting the conversation. You appear to have examined gonorrhea, chlamydia, and furunculosis as possible diagnosis for the patient’s symptoms. However, based on the facts supplied and current evidence from the literature, I would want to present a different viewpoint. While gonorrhea and chlamydia are prevalent sexually transmitted diseases (STIs) that might create symptoms similar to what the patient is experiencing, there are a few characteristics that suggest herpes simplex virus (HSV) infection. Patients with HSV can have painful sores around the genitals, dysuria, discharge, and swollen lymph nodes, according to Omarova et al. (2022). The presence of vesicular lesions on the left labia, discomfort on probing, and a description of thin, clear to white vaginal discharge are all consistent with HSV clinical presentation. Furthermore, the absence of urinary urgency or frequency, which are typically linked with gonorrhea and chlamydia, lends credence to HSV infection.

I would prescribe certain diagnostic testing to validate the diagnosis. While urine pregnancy testing is useful for ruling out pregnancy, it may be unrelated to the patient’s current symptoms. Instead, I would recommend a pelvic examination to look for any lesions, discharge, or anomalies, as well as to check the cervix for any cervical motion tenderness. If HSV lesions are present, visual inspection can assist identify them. I would propose performing HSV nucleic acid amplification tests (NAATs) or PCR amplicons on a sample collected from the vesicular lesions to conclusively identify HSV and define the type of infection as either HSV-1 or HSV-2. Given the patient’s sexual history and the likelihood of other STIs, testing for co-infections is critical. NAATs can be used to test for Chlamydia trachomatis, Neisseria gonorrhea, and Trichomonas vaginalis all at the same time (Van et al., 2023). These tests are extremely accurate and produce consistent findings.

While HIV testing is an important element of sexual health screening, it is crucial to note that due to the patient’s recent exposure, the HIV nucleic acid test (NAT) may not detect the virus within 10-33 days after exposure (Centers for Disease Control and Prevention, 2022). As a result, repeating the HIV test at a later period may be required to obtain an accurate result. In terms of therapeutic suggestions, your idea of HSV antiviral therapy is appropriate. However, it is critical to follow treatment recommendations from trustworthy sources such as the Centers for Disease Control and Prevention (CDC) or local health authorities. For the first outbreak of genital herpes caused by HSV-2, antiviral therapy such as acyclovir, valacyclovir, or famciclovir is commonly prescribed for 7-10 days (Omarova et al., 2022). The drug used and the duration of treatment may differ depending on local guidelines and individual patient characteristics.

In terms of prophylactic treatment for other potential STIs, treatment options must be based on evidence-based guidelines and the patient’s particular risk factors. Antibiotics should be prescribed prophylactically only after consulting with an experienced healthcare professional and taking into account local antibiotic resistance patterns as well as the patient’s individual needs.

References

Centers for Disease Control and Prevention. (2022, June 22). Understanding the HIV Window Period | Testing | HIV Basics | HIV/AIDS | CDC. https://www.cdc.gov/hiv/basics/hiv-testing/hiv-window-period.html

Links to an external site.

Van, C. E., Malleson, S., & Grennan, T. (2023). A practical approach to the diagnosis and management of chlamydia and gonorrhea. CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 195(24), E844–E849. https://doi.org/10.1503/cmaj.221849

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