Case Study:
Geri is a 18-year-old high school student in your clinic today because of vaginal discharge. You have seen Geri three times this past year for the same complaint and have diagnosed chlamydial cervicitis two of the three times. The other time Geri had bacterial vaginosis.
Chief Complaint: Lots of yellow vaginal discharge
HPI: yellow discharge X3 weeks with odor especially after sex; started burning with urination 2 days ago; denies vaginal/vulvar sores or irritation; says has noticed some itching on the outside.
PMH: allergy to PCN and sulfa; OCP’s x 2 years for birth control; no other meds
OB/GYN: no pregnancies, LMP 1 week ago; Paps UTD and WNL; Hx chlamydia cervicitis treated with doxycycline.
FH: Mother with HTN (smoker)
SH: Lives with mother and sister (parents divorced); currently in apartment with mother’s sister and her boyfriend because her mother is out of work; smokes 1/2 ppd x 2 years; 4-6 beers every week-end; marijuana every week-end; denies other recreational drugs; junior in high school and works at Hardees.
Exam:
Abdomen soft non tender
inguinal lymph without adenopathy
perineum normal hair distribution; no lesion or discharge
vagina rugated, slightly erythematous, large amount yellow green discharge; no lesion
cervix; nullip, erythematous; no exudate at os, mobile, slightly tender, with palpation
uterus firm, mobile, non-tender
adnexae without palpable mass or tenderness bilateral
rectovag confirms findings
Lab
urine dip-neg blood, neg leuks, neg nitrates
KOH wet prep neg hyphae, spores
NaCl wet prep pos trichomonads, neg clue, pos whiff, pos WBC,s neg RBC’s rare lactobacilli
Questions
- Would you perform a pelvic exam and/or a pap smear?
- What is your Diagnosis (Assessment)?
- What is your Plan, including treatment and education?
- Would you prescribe treatment for her partner(s)?
- What contraceptive care/counseling would you offer Geri?
- List 2 community resources in your are that you could utilize.
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