Abdominal Pain with Smelly Vaginal Discharge Essay

Abdominal Pain with Smelly Vaginal Discharge Essay

Abdominal Pain with Smelly Vaginal Discharge Essay

Subjective

Patient:  Initials: K.T, Age: 32 years, Sex: Female

Chief Complaint: “Abdominal pain with smelly vaginal discharge.”

History of Present Illness: 

K.T is a 32-year-old Hispanic female with complaints of abdominal pain and foul-smelling vaginal discharge. She states that the abdominal pain started about two weeks ago and is intermittent. She also started experiencing foul-smelling vaginal discharge about a week ago. The abdominal pain occurs in the lower abdomen bilaterally, lasting 10-15 minutes each episode. The patient describes the abdominal pain as constant and crampy, and aggravated by movement and sexual activity. Besides, she describes the vaginal discharge as mucoid and whitish. K.T has been taking Tylenol to relieve the abdominal pain, but it has not been effective. The symptoms are associated with burning irritation when passing urine, pain during coitus, and slight vaginal bleeding afterward. She rates the abdominal pain at 3/10.

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Past Medical History:  No history of chronic conditions but reports a prolonged history of recurrent genital infections like Bacterial vaginosis and Trichomoniasis.

Past Surgical History:  No surgical history.

Medications:  OTC Tylenol 500 mg to alleviate abdominal pain.

Allergies: No known food or drug allergies.

Immunizations:  Immunization is current. Last TT- 2 years ago; Flu shot- 8 months; COVID- fully vaccinated.

Family History:  The patient’s maternal grandmother died at 83 years from ovarian cancer. She has a maternal aunt with Breast Cancer. The paternal grandfather has Alzheimer’s.

Social History/Risk Factors:  The patient studied up to high school level and currently works as a waitress in a restaurant. She is single and has no children but lives with her sister. She admits to taking alcohol 2-3 beers after her shift, smokes 1PPD, and uses recreational marijuana. The patient reports that she has an IUD and does not use condoms. She mentions that she currently has three sexual partners. Her hobbies include watching movies and visiting museums. She denies a history of domestic violence.

Review of Systems:

List each system with pertinent positives and negatives:

General:  Positive for fever and general body weakness. Negative for chills, appetite/weight changes, or changes in exercise ability.

Head: Negative for headache, dizziness, or sinus pressure.

Eyes: Negative for double vision, visual loss, excessive tearing, or eye pain. 

Ears: Negative for ear discharge, hearing loss, or ear pain.

Nose: Negative for sneezing, difficulty smelling, nasal congestion, nasal drip, or epistaxis.

Mouth/Throat: Negative for swallowing difficulties, eating difficulty, mouth sores, or sore throat. Last dental exam: 2 years ago.

Neck: Negative for neck stiffness, pain, or reflux.

Respiratory: Negative for difficulty breathing, cough, shortness of breath, wheezing, bloody sputum, or chest pain.

Cardiovascular: Negative for chest pain, palpitations, edema, or dyspnea with exertion.

GI: Positive for lower abdominal pain. Negative for anorexia, nausea, vomiting, diarrhea, or tarry stools.

GU: Positive for pelvic pain and painful urination. Negative for urinary frequency and urgency.

GYN: Positive for postcoital bleeding, malodorous vaginal discharge, and dyspareunia. LMP-3 weeks ago.

Musculoskeletal: Negative for muscle pain, joint pain/stiffness, or limitation of movement.

Neurological: Negative for headache, tingling sensations, fainting, or muscle weakness.

Psychiatric: Negative for history of anxiety, depression, sleep disturbances, suicidal ideation, or suicidal attempts.

Skin: Negative for skin-color changes, itching, or rashes.

Endocrine: Denies excessive thirst, increased urine production, extreme hunger, or intolerance to heat or cold.

Hem/Lymph: Negative for bruising, delayed wound healing, or anemia.

Objective

Vital Signs: Ht: 5’5    Wt.: 140 lbs.   BMI: 23.3 

P-78;   T: 101.48 F     RR: 16, BP: 134/80     O2 Sat-99%

General: Adult female patient in no acute distress. She is neat and appropriately dressed. She maintains eye contact and speaks at a normal rate and volume.

Neurological: Normal gait and posture. Alert and oriented x3. Normal speech.

HEENT: Head is symmetric, normocephalic, and atraumatic. Sclera white and conjunctiva non-inflamed. Normal nasal turbinate. 

Neck: Full ROM, Non-palpable cervical lymph nodes, Trachea is midline. The thyroid gland is normal.

Lymph Nodes: Non-palpable.

Respiratory:  Uniform chest rise and fall; Unlabored breathing; No chest wall deformities; Lungs clear on auscultation.

Cardiovascular: Regular heart rhythm; S1 and S2 present; No S gallop, heart murmurs, carotid bruits, or friction rubs.

GI: Normoactive bowel sounds; Abdominal tenderness on the lower right and left quadrants; Rebound abdominal tenderness. No abdominal masses or organomegaly. 

Genital and Rectal: Mucopurulent vaginal discharge; Uterine tenderness; cervical motion tenderness; Tender adnexal mass. No rectal ulcers or fissures.

Back: Well-aligned spine.

Musculoskeletal: Full ROM in all extremities.

Skin: Brown, warm and dry, intact skin. No hypopigmentation or lesions

Psychiatric (affect, mood): The self-reported mood is okay. Affect is appropriate.

 Diagnostic Results: WBC count:  Elevated

Assessment

Pelvic Inflammatory Disease (PID): PID is an infectious disease that manifests with inflammation of the upper genital tract in females. The commonly infected/inflamed organs include the fallopian tubes, endometrium, and organs adjacent to the pelvis. Pathogens mostly attributed to PID include Chlamydia and gonococci, but pathogens causing bacterial vaginosis can also cause PID (Curry et al., 2019). The pathogens ascend from the lower genital tract causing infection in the upper tract. The classic symptom of PID is lower abdominal pain, usually bilateral, dull, cramping, or aching, and constant. Other common PID symptoms include fever, nausea, vomiting, abnormal vaginal discharge, painful urination, dyspareunia, and abnormal vaginal bleeding, mostly postcoital bleeding (Curry et al., 2019). Physical exam findings in PID include abnormal mucopurulent cervical or vaginal discharge, cervical motion tenderness, and uterine and adnexal tenderness on pelvic exam.

PID is a differential diagnosis based on the patient’s clinical manifestations of lower abdominal pain, abnormal vaginal discharge dyspareunia, bleeding after intercourse, dysuria, and fever. In addition, physical findings of fever, uterine tenderness, cervical motion tenderness, and tender adnexal mass point to PID. The elevated WBC count indicates an underlying infection.

Cervicitis: Cervicitis is an inflammation of the cervix. Infectious cervicitis primarily occurs from an STI caused by Chlamydia trachomatis, N. gonorrhea, or herpes simplex. Clinical manifestations of cervicitis include increased vaginal discharge, dysuria, genital burning and itching, urinary frequency, pelvic or lower abdominal pain, and postcoital or intermenstrual bleeding (Dionne-Odom & Marrazzo, 2020). Speculum exam findings include an inflamed and edematous cervix, friable cervix, and thick yellow or green pus from the cervical os. Cervical motion tenderness is also present on pelvic exam (Dionne-Odom & Marrazzo, 2020). Cervicitis is a differential diagnosis based on positive symptoms of lower abdominal pain, abnormal vaginal discharge, dysuria, postcoital or intermenstrual bleeding, and cervical motion tenderness. However, the absence of a strawberry cervix and yellow/green discharge makes cervicitis an unlikely primary diagnosis.

Urinary tract infection (UTI): The classic symptom of UTI is dysuria (painful urination or burning sensation). The dysuria is often accompanied by urinary urgency and frequency. Other common UTI symptoms include lower abdominal pain/flank pain, a full bladder sensation, blood in the urine, malaise, fever, and chills (Abou Heidar et al., 2019). Objective findings include suprapubic tenderness and CVA tenderness. Pertinent findings that support UTI as a differential diagnosis include lower abdominal pain, painful urination, fever, and elevated WBC.

Plan

Further diagnostic testing:

Nucleic Acid Amplification Tests (NAATs): NAATs will be ordered to test the patient for Chlamydia Trachomatis. It is highly preferred to test for Chlamydia trachomatis since it is sensitive to the pathogen and is non-invasive as it does not require a urethral swab or pelvic exam (Curry et al., 2019).

Pharmacologic therapy: The treatment guidelines recommend that patients with PID be prescribed empirical broad-spectrum antibiotics that are effective against N. gonorrhoeae, C.trachomatis, and gram-negative bacteria (Savaris et al., 2019). The patient will be treated as an outpatient using:

1. Ceftriaxone 250 mg IM STAT.
2. Oral Flagyl 400 mg BD for 14 days.

• Doxycycline 100 mg BD for 14 days

Patient education

The patient will be educated on safe sexual practices, such as practicing discriminative sex by limiting the number of sexual partners. She will be educated on using barrier contraceptives such as condoms to lower the risk of STIs and PIDs in the future (Curry et al., 2019). In addition, she will be recommended to bring her sexual partners for STI screening and treatment. Education on medication adherence will be provided to prevent reinfection or the spread of the infection to other adjacent organs. Furthermore, she will be advised to abstain from alcohol and sexual activity during treatment and avoid sex until the symptoms have abated.

Follow-up: The patient will be followed-up after 14 days to evaluate her response to treatment and assess for complications.            

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), 339–346. https://doi.org/10.4103/UA.UA_104_19

Curry, A., Williams, T., & Penny, M. L. (2019). Pelvic Inflammatory Disease: Diagnosis, Management, and Prevention. American family physician, 100(6), 357–364.

Dionne-Odom, J., & Marrazzo, J. (2020). Cervicitis: Balancing the Goals of Empiric Therapy and Antimicrobial Stewardship to Improve Women’s Health. Sexually transmitted diseases, 47(6), 387–388. https://doi.org/10.1097/OLQ.0000000000001183

 Savaris, R. F., Fuhrich, D. G., Duarte, R. V., Franik, S., & Ross, J. (2019). Antibiotic therapy for pelvic inflammatory disease: an abridged version of a Cochrane systematic review and meta-analysis of randomized controlled trials. Sexually transmitted infections, 95(1), 21–27. https://doi.org/10.1136/sextrans-2018-053693

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Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.

Subjective

CC (Chief complaint)
HPT (History of present illness)
History (Pertinent medical, surgical, social, medications, exposure, family history, allergies, vaccines)
ROS (Review of systems)
Objective

Vital signs/BMI
Physical exam findings
Diagnostic results (include actual “results” or “findings” that you would expect for a certain scenario)
Assessment/Plan

Differential list and rationale for final/working diagnosis
Problem list
Plan for Each Problem

Based on evidence with proper references
Further diagnostic testing you would order
Nonpharmacologic therapy
Pharmacologic therapy, including specific medication dose
Frequency and duration of therapy
Patient education
Follow-up