Reference no: EM133226971
Question - Case Study - A high school senior comes to your office for a physical exam to allow her to participate in sports at school. She denies any problems.
While taking her history, she admits that she is sexually active and has had three sexual partners in the past year, but has never used any form of birth control other than the occasional use of condoms with one of her partners.
History -
Shy when talking about her sexual practices
Has never had a pelvic exam
Her periods have been regular, but she has recently noted some spotting between periods. Her last menstrual period was 3 weeks ago.
Denies vaginal discharge, dyspareunia, genital lesions or sores
Your Physical Exam Findings are:
Vital signs: blood pressure 118/68, pulse 74, respiration 18, temperature 37.1oC
Breast, thyroid, and abdominal exam within normal limits
Orthopedic exam within normal limits - no scoliosis noted, joints limber without limited range of motion.
The genital exam reveals normal vulva, and vagina.
Pelvic exam - cervix appears inflamed, bleeds easily, with a purulent discharge coming from the cervical os.
The bimanual exam is normal without cervical motion pain, uterine or adnexal tenderness.
Please answer these questions without looking ahead at more information:
1. Based on this patient's history and physical exam, list your differential diagnosis.
2. What are the possible etiologic agents associated with the clinical findings?
3. Based solely on the history and physical assessment data, what is the most likely diagnosis?
Now look at the following laboratory results:
NAAT for Chlamydia trachomatis: positive
NAAT for Neisseria gonorrhoeae: negative
RPR: negative
Wet mount: pH 4.2, no clue cells or trichomonads but numerous WBCs
KOH preparation: negative for "whiff test"
HIV antibody test: negative
Pregnancy test: negative
Answer the next set of questions based on the laboratory results and patient history.
4. What is the final diagnosis?
5. What is the appropriate treatment?
6. What educational counseling would you provide for this patient?
7. Who is responsible for reporting this case to the local health department?
Partner Management: Since this patient has had 3 sexual partners during the past year, how should these partners be managed?
Partner 1 - Last sexual exposure 5 months ago
Partner 2 - Last sexual exposure 4 weeks ago
Partner 3 - Last sexual exposure 2 weeks ago
8. Which sex partners should be evaluated, tested, and treated?
9. Would you prescribe any other medications or treatment for this patient?
10. When would you schedule a follow up exam for your patient, and what will be done at that visit?