Reference no: EM133629148
A 25-year-old African American female patient presents to the office with c/o vaginal discharge 3 weeks ago. Patient states it smells "fishy." Patient describes the vaginal discharge as thin and gray. Patient reports burning during urination, dyspareunia, vaginal itching, and pelvic tenderness. Patient reports odor has gotten worse a week ago. Patient reports vaginal discharge odor becomes more pronounced after sexual intercourse. Patient reports used douche which worsened symptoms. Denies fever, chills or fatigue. Patient has one sexual partner and states her partner denies any symptoms. Patient reports uses condom during sexual intercourse. LMP 11/21/2023. Patient report pain level of 5 out of 10 on numerical scale and describes pain as cramping. Patient is stable. Patient was slightly anxious.
Pelvic exam was done - Revealed erythema to bilateral inner labia and gray thin discharge present. Speculum exam - malodorous mucus-like discharge around cervix. Bimanual: generalized pelvic tenderness.
Diagnostic results: Pelvic exam
Aptima vaginal swab obtained, F/U results
Urine culture sent, F/U results
Urine dip in the office - all negative except 1+ blood
Treatment: Tylenol PRN for pain
Metronidazole 500 mg PO BID X 7 days for bacterial vaginosis
Primary diagnosis is : Bacterial vaginosis
Question:
Include in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor's treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
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