Year Woman Presents Explained for Students (Easy Guide)
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Key Explanation
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Original Question
N.N., a 25 year old woman presents to the office with one week of vaginal discharge. She describes this as green-yellow in color with a bad odor. She has never had this before. She says the symptoms started along with vaginal soreness after she had sexual intercourse. She denies any itching. She is sexually active & prevents pregnancy with an intrauterine device (IUD). She has been with one male partner for the past 3 months, and he has no symptoms. She states she had first intercourse at age 15 and has had multiple sexual partners. She had a chlamydial infection 2 years ago that was treated with oral antibiotics. Her LMP was 2 weeks ago. She denies any recent antibiotic treatment. Physical exam: Afebrile, normal vital signs. General physical exam is normal. On pelvic exam, she has normal external genitalia. She has a small amount of frothy, homogenous green-gray discharge at the introitus. The cervix has a “strawberry” red appearance with a slight amount of discharge noted coming from the os. The IUD string is in place. Labs: Chlamydia & gonorrhea specimens are obtained from the cervical os, and a sample of the vaginal discharge is collected for microscopic evaluation. Wet mount slide (saline): motile trichomonads and many white blood cells. Urine pregnancy test is negative. 1. You identify the presenting problem of the patient. 2. You verbalize your initial choice of pharmacotherapy for this patient. 3. You identify further management for this patient. 4. You identify any necessary patient education.
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