Transcript Case Presentation

Kimberly Henry
State University of New York
Institute of Technology
February 12, 2014
RO is a single 22 year old African American female
presenting to the OB/GYN office to establish care on
02/06/2014
CC: Pt states “I am here for my annual exam and I want
to talk about my infections”
HPI: RO has had pelvic pain and discharge which comes
and goes for about 1 month. Pain is not related to
ovulation or menses. Menses is irregular, light flow
and occurs every other month. LMP 01/03/2014. RO
has not tried any OTC products for pain relief. Admits
to recurrent vaginal infections (>3 per year). Discharge
is foul smelling and clear to white in color.
Health History
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Medical Illnesses: Denies
Psychiatric Illnesses: Denies
Injuries/Accidents: Denies
Surgeries: Denies
Hospitalizations: NSVD 2012, Crouse Hospital Syracuse, NY 40 weeks,
male 6#14oz
Transfusions: Denies, but agrees to
Blood Type: A+
Childhood illnesses: Denies
Immunizations: Up to date for age, did not receive Gardisil series, does
not want influenza vaccine
Allergies: Denies medication, environmental, food or latex allergy
Current Medications: none
Family history: Father, alive age 52, Renal disease
Mother, alive 49, HTN
Maternal aunt, alive, 45, breast CA (brca unk)
RO resides in a 2 family home with her 18 month old
son. She has adequate access to telephone,
refrigeration, heat and water. RO is high school
educated and is employed outside the home in retail.
Home does not contain firearms or pets. Water is
fluorinated. Home does contain working smoke
detectors. RO uses seat belts while in a moving
vehicle. RO denies any cultural or spiritual concerns
at this visit. RO was born in PA and she denies any
tobacco or recreational drug use. Admits to
occasional alcohol consumption. Admits to
occasional caffeine intake. Admits to a moderate
amount of exercise weekly. Currently is not sexually
active.
Review of Systems
Denies fevers, chills, fatigue, night sweats, hot/cold
intolerances, unintentional weight gain or loss
GYN: G1 P1 T1P0A0L1
Age of menarche is 12. Pre-menopausal. LMP 01/03/2014.
Last Pap exam 2012. Menses are irregular, light flow.
Admits to vaginal itching, vaginal discharge, foul odor.
Admits to pelvic pain x 1 month. Denies hx of abnormal
paps. Denies breast lumps, breast pain, and nipple
discharge. Denies hx of STD’s. Denies douching. Admits
to recurrent vaginal infections
GU: Denies dysuria, hematuria, polyuria, incontinence,
CVA tenderness/pain, hx of stones or infections
GI: Denies food intolerances, dysphagia, heartburn,
nausea, vomiting, constipation, diarrhea, hemorrhoids,
ulcers, hx of hepatitis or jaundice. Had in office sono
today
Physical Exam
Vital signs: 108/64 RR: 14 HR 65 Temp 37.2 Height 62”
Weight 146 lbs BMI 26.7
Sono report: Showed endometrial thickness of 7.2mm, no
fluid in the cul de sac, and a possible polyp in EC. Left
ovary 3.0cm x 1.8cm x 2.2cm with no evidence of a mass or
cyst. Right ovary 3.3cm x 2.1cm x 1.9cm with a 3.6cm simple
cyst noted. Color flow visualized in both ovaries
General: Well developed, well nourished, well groomed 22 yr
old, AOx3, in no apparent distress. Pleasant and
cooperative.
Skin: Warm, dry, intact. Absent of pallor or cyanosis. No
impressive skin lesions observed
Neck: Symmetrical, trachea midline, supple, absent of
adenopathy or thyromegaly. ROM intact
CV/PV: RRR, S1 and S2 intact, absent of murmurs, rubs,
or gallops. Capillary refill <3 seconds. Absent of bruits.
Absent of peripheral edema. +2 peripheral pulses
Respiratory: Symmetrical, breath sounds equal
bilaterally and clear. Absent of pain on
inspiration/expiration
Abd: Soft, symmetrical, +bowel sounds present in the 4
quadrants, +striae, absent of other scars or lesions. +
discomfort RLQ no other guarding or pain on palpation.
Absent of organomegaly or palpable masses
MS: Ambulates without assistance, able to get into lithotomy
unassisted. Full ROM of all extremities and back, absent of
skeletal tenderness and joint deformities.
Neuro: Appropriate affect, speech intact, oriented to person,
place, and time. Absent from preoccupation of abnormal
thoughts.
Breast: Symmetrical, nipples unremarkable, absent of
dimpling, masses, lesions, or discharge. Absent of axillary
adenopathy and breast tenderness
GU:
External: Public hair normally distributed. Clitoris and
labia unremarkable. Normal glands. Perineum and
perianal area unremarkable
Internal: Urethra unremarkable and absent of discharge.
Strong foul odor detected, vaginal mucosa contains
thin white discharge. Cervix normal to inspection and
palpation without cervical motion tenderness. Uterus
palpable, anteverted, normal in size, absent of uterine
and adnexal tenderness. Ovaries palpable, R cyst
palpable and tender. Left ovary normal to palpation
Any thoughts on the DDX?
Differential Diagnoses
 Vaginitis caused by BV, Yeast, or Trichomoniasis
 Cervicitis from GC/Chlamydia
 Normal cervical mucus
 UTI
 Contact/Allergic Dermatitis
 Lichen planus
 Lichen Simplex Chronicus
Vagina’s are happiest when their Ph is around 4.0-4.5
Keeping your vagina within these parameters is not easy
Semen~ ph 7.1-8.0
Blood~ ph 7.4
This is why most symptomatic women will complain of
BV after sexual intercourse or menses
Vaginal Cultures:
Affirm
One Swab
(more expensive testing,
but helps with finding
causative agent to
recurrent BV
2010 CDC Treatment
guideline for BV
Metronidazole (Flagyl) 500mg PO BID for 7 days OR
Flagyl gel 1 5gm applicator PV QHS for 5 days OR
Clindamycin vag cream 1 applicator PV Q HS for 7 days
Alternatives:
Tinidazole (Tindamax) 2gm PO Q Day for 2 days OR
Tindazole 1gm PO Q Day for 5 days OR
Clindamycin Ovules 100mg PV QHS for 3 days
Recurrent BV
Long term suppressive therapy may be needed in
symptomatic woman with more than 3 episodes in a 12
month period
Some woman go through a cyclic pattern of treating the
BV but then developing Candida from changing the
vaginal ph
No consistent guidelines on long term therapy
UptoDate reports using Vaginal Metrogel or Oral Flagyl
for 7 days followed by Metrogel 2x week for four to six
months. Improved results occurred by adding vaginal
boric acid 600mg at bedtime for 21 days after initiation
of 7 day Metrogel or Flagyl
Patient Education
 The best way to eradicate the offending agent, one
should abstain from sexual intercourse during therapy
 Thoroughly clean all sex toys which may harbor
bacteria
 Probiotics may help with ph balance, but not proven
References:
 Baldor, R. A., Golding, J., & Grimes, J. A. (2014). The 5-
minute clinical consult 2014 (22nd ed.). Philadelphia,
PA: Lippincott Williams & Wilkins.
 Sobel, J. (2014). Bacterial Vaginosis. In D.S.Basow
(Ed), UpToDate. Retrieved from
http://www.uptodate.com