We can work on Gonorrhea and Trichomonas

Case Scenario 1

Table 1
Infection Description Presentation Causes/ Risk Factors Treatment per CDC Addtl info
Candida
BV
Chlamydia
Gonorrhea
Trichomonas
Cervicitis
PID
HIV
Syphilis
Hep B
Hep C
HSV

Table 2
Question Answer
Name 10 Risk Factors for contracting STI’s and HIV

Name 5 safer sex practices

Can HIV be transmitted through sweat, saliva, and tears? (Include rationale)
Name 2 types of intercourse are at the highest risk for contracting HIV
Why are women more susceptible to HIV in a male to female relationship (versus a male contracting it from a female)?

Lisa is a 19-year-old female who presents to the clinic c/o abnormal vaginal discharge for one week after having unprotected vaginal intercourse with a new male partner she has been dating for a couple of weeks. Lisa’s pregnancy test is negative and her LMP was 2 weeks ago. As her health care provider, you will need to perform testing to determine if Lisa has contracted a sexually transmitted infection or other vaginal infection.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

  1. Subjective:
    a. What other relevant questions should you ask regarding the HPI?
    b. What other medical history questions should you ask?
    c. What other social history questions should you ask?
  2. Objective:
    a. Explain what POCT will you order and perform, and discuss your rationale for ordering and performing each test.
  3. Assessment/ Diagnosis:
    a. What would be an appropriate diagnosis for her? Why?
    b. Any other diagnosis or differential diagnosis you would like to add?
  4. Plan:
    a. What will you prescribe for this patient? Why? (assume one of your lab test results is positive), Explain what medications and treatments you would recommend
    b. Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s), partner notification, and follow-up plan of care.
    c. What patient education is important to include for this patient? (Consider when can the patient resume sexual activity)
    d. Explain complications that can occur if patient does not comply with treatment regimen.
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Sample Answer

 

 

 

Table 1: Sexually Transmitted Infections (STIs) and Other Infections

Infection Description Presentation Causes/Risk Factors Treatment per CDC Addtl Info
Candida (Yeast Infection) Fungal infection of the vagina. White, cottage cheese-like discharge, itching, burning, redness. Antibiotic use, high estrogen levels, diabetes, weakened immune system. Antifungal medications (fluconazole, clotrimazole). Not strictly an STI but can be triggered by sexual activity.
Bacterial Vaginosis (BV) Bacterial imbalance in the vagina. Thin, gray or white discharge, fishy odor, itching. Multiple sexual partners, douching, lack of lactobacilli. Metronidazole, clindamycin. Not strictly an STI but can be triggered by sexual activity.
Chlamydia Bacterial infection. Often asymptomatic; possible abnormal discharge, burning urination, pelvic pain. Unprotected sex. Azithromycin or doxycycline. Can lead to pelvic inflammatory disease (PID) and infertility.
Gonorrhea Bacterial infection. Often asymptomatic; possible abnormal discharge, burning urination, pelvic pain. Unprotected sex. Ceftriaxone. Can lead to PID and infertility.
Trichomoniasis Protozoan infection. Yellow-green frothy discharge, itching, burning, foul odor. Unprotected sex. Metronidazole or tinidazole. Partner treatment is essential.
Cervicitis Inflammation of the cervix. Abnormal vaginal discharge, bleeding between periods, pelvic pain. STIs (chlamydia, gonorrhea), allergies. Treat underlying cause. Can lead to PID.
Pelvic Inflammatory Disease (PID) Infection of the female reproductive organs. Pelvic pain, fever, abnormal discharge, pain during sex. Untreated STIs (chlamydia, gonorrhea). Ceftriaxone plus doxycycline, metronidazole Can cause infertility and ectopic pregnancy.
HIV Viral infection that attacks the immune system. Flu-like symptoms, fatigue, weight loss, opportunistic infections. Unprotected sex, sharing needles, mother-to-child transmission. Antiretroviral therapy (ART). Chronic condition, not curable.
Syphilis Bacterial infection. Sores (chancres), rash, fever, fatigue, neurological problems. Unprotected sex. Penicillin. Can cause severe complications if untreated.
Hepatitis B (Hep B) Viral infection of the liver. Fatigue, abdominal pain, jaundice. Unprotected sex, sharing needles, mother-to-child transmission.

Full Answer Section

 

 

 

 

  • Sexual activity and partner history?
  • Substance use (drugs, alcohol, tobacco)?
  • Living situation and support system?

O (Objective):

  • Physical exam: Pelvic examination will be conducted. Observation of discharge, cervical visualization.
  • POCT (Point-of-Care Testing):
    • Wet mount: To identify trichomoniasis, bacterial vaginosis, or yeast.
    • pH testing: To assess vaginal pH (elevated pH can suggest BV or trichomoniasis).
    • Rapid chlamydia and gonorrhea test: To detect these common STIs.
    • Rationale: The tests are performed to rapidly identify the cause of the vaginal discharge so that rapid treatment can be provided.

A (Assessment/Diagnosis):

  • a. Appropriate Diagnosis: Based off of the Case scenario, a diagnosis of a STI such as chlamydia, gonorrhea, or Trichomoniasis is highly possible.
  • b. Differential Diagnoses:
    • Bacterial vaginosis (BV)
    • Vulvovaginal candidiasis (yeast infection)
    • Cervicitis

P (Plan):

  • a. Prescription/Treatment (Assuming Chlamydia is Positive):
    • Azithromycin 1g orally in a single dose. This is a first-line treatment for chlamydia per CDC guidelines.
  • b. Treatment Guidelines/Side Effects:
    • Azithromycin side effects: Nausea, vomiting, diarrhea, abdominal pain.
    • Partner notification and treatment are essential.
    • Follow-up testing is recommended in 3 months.
    • Avoid sexual intercourse for 7 days after treatment completion or until partners are treated.
  • c. Patient Education:
    • Importance of completing the full course of antibiotics.
    • Safe sex practices, including consistent condom use.
    • Risks of untreated STIs.
    • The patient must not engage in any sexual activity for seven days after treatment, and until any sexual partner has also been treated.
  • d. Complications of Noncompliance:
    • PID, infertility, ectopic pregnancy, chronic pelvic pain.
    • Continued transmission to sexual partners.
    • Increased risk of HIV transmission.

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