NRNP 6552 Common Gynecologic Conditions, Part 2

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

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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

First 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

Hello,

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