Dysmenorrhea and Bacterial Vaginosis Diagnostics

Name:E.A. S O A P Time:11.15p.m.
Date:10/12/2017 Age:26 y/o Sex:F
SUBJECTIVE
CC:
Vaginal itchiness and discharge.”
HPICC Vaginal itchiness
Case of a 26-year-old female, that presents to the office with recurrent vaginal discharge vaginal itchiness for one week. She noticed a fishy odor with the secretions. She is worried because she never had any sexually transmitted diseases in the past. She denies pelvic pain or vaginal bleeding. Her last menstrual period was 2 weeks ago, she is using condoms with her boyfriend. She is working as a waitress and has a healthy boy 4 years.old.
Medications:
Fioricet Tab PRN Headache
PMH
Allergies: The patient states that she does not suffer from any environmental, food, or drugs allergies
MedicationIntolerances:
NKDA
ChronicIllnesses/Major trauma
Tension Headaches
LMP three weeks ago 5d duration regular
The patient denies having major traumas.
FamilyHistory
Father is alive. Negative for cancer, heart disease, hypertension, tuberculosis, other medical illnesses.
Mother is alive. Has Hypertension. Negative for cancer, heart disease, tuberculosis, other medical illnesses
social history
The patient is socially active. She is working in a restaurant, practices jogging. She does not use tobacco or drugs, she drinks a glass of wine every week. She only has sexual activity with her boyfriend using condoms.
ROS
General Cardiovascular
The patient has no problems with weight. She deniesweight loss/gain, fever, and night sweats. She does not have cardiovascular problems She denies chest pain, edema, orthopnea, etc. In the course of the examination, no symptoms or problems are discovered.
Skin
No reports of rash, lesions, delayed healing,bruising,bleedingorskindiscolorations. The patient deniesanychangesinmoles.
Respiratory
The patient deniesshortnessofbreath,cough,congestion,wheezing,hemoptysis,dyspnea,pneumonia.There is also no tuberculosis history.
Eyes
No reported problems with sight. The patient deniesblurring,visualchangesofanykind.She does not visit ophthalmologists regularly because does not feel the need for it.
Gastrointestinal
She has no complaints about the gastrointestinal system. The patient’s abdominal pain bloating, diarrhea, or constipation.
Ears
The patient has never experienced ear pain, hearing loss, ringing in ears, etc. There are no signs of ear traumas or hearing loss.
Genitourinary/Gynecological
The patient noticed vaginal discharge grey thin mucus and vaginal itchiness within the past week along with vaginal itchiness and a fishy odor.
LMP Last week last 5 days 3 weeks ago
Menarche:12Y/o G1 P 1
NohistoryofSTDsorvaginalinfections.
Pap Smear. Last year Normal
Nose/Mouth/Throat
The patient does not have any oral cavity diseases. Moist oral mucosa no less edema or erythema.
Musculoskeletal
Musculoskeletal development is normal. No signs of dystrophy. The examination does not demonstrate any visible problems in the sphere.
Breast
There are no signs of breast lesions. The patient denieslumps,bumps, or changes.There is no breast cancer history in the family.
Neurological
She does not experience spontaneous episodes of weakness, memory loss, mental problems.
Heme/Lymph/Endo
The patient is not a donor. She denies blood transfusion. She denies extreme sweating, alterations in her appetite, etc.
Psychiatric
Denies depression, sleeping disorder, suicidal attempts, etc.
OBJECTIVE
Weight:149lbs BMI:23.3 Temp:97.1tympanic BP:128/77rightarmsitting
Height:5’7 Pulse:80 x min Resp:14 x min. Oxy Sat 100%
general appearance
Female not in distress cooperative answers willingly and appropriately.
Skin
The patients skin is warm, clean, without spots, or some other problems.
HEENT
The patients head is normocephalic. It is symmetric. There are no lesions. Her hair is distributed by the sex character. No tenderness. No signs of major traumas.
The patients eyes demonstrate no abnormal signs. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The sclera is clear.
Ears: Landmarks are visualized. No signs of problems with hearing. Positive light reflex.
Nose: No visible septum deviation. The mucosa is fine and pink. There are no deviations.
Neck: Symmetric no nodes no thyromegaly/
Teeth are normal no gingival edema.
Cardiovascular
No extra sounds are discovered during the patients investigation. The rate and rhythm are regular. Capillary refill – 1,5 seconds. There is noedema.
Respiratory
The patients chest wall is symmetric expansion. She demonstrates regular respirations. There are no problems with breathing.
Gastrointestinal
The patients abdomen is round, soft. Responds to palpation in a normal way. Active in all quadrants.
Breast
Breast No signs of breast cancer. No calcifications. The overall state could be described as normal.
Genitourinary
Externalexam:Vulvalooks with edema, pubic hair shaved,introits is red-pink with thin grey secretion. on the walls. Pelvic examination shows vaginal mucosa red-pink, with edema and erythema, and yellow mucus os is closed, bimanual exam shows uterus anteverted no masses, tender to palpation mucosal samples taken. Adnexa is palpable. No masses, tender to palpation no rebound, no guarding Rectal exam demonstrates the absence of pain, masses, or signs of traumas. No bleeding.
Musculoskeletal
The patient demonstrates no pain when moves. All gestures are painless. The locomotor apparatus is fine.
Neurological
The patients speech is clear. She responses to all answers in an appropriate way. Demonstrates an appropriate level of cognitive activity. Reflexes are intact. The balance is stable. No visible neurologic diseases.
Psychiatric
The patient maintains eye contact. Their speech is clear. Understands all questions. Demonstrates anxiety because of the pain during menses. No visible signs of mental disorders. The family history also does not contain any records of this sort.
lab tests
Vaginal Ph:4.7
Vaginal secretion microscopic analysis: Lactobacillus – 2, Bacteroides / Gardnerella – 4, and Mobiluncus – 2 (bacterial vaginosis)
CBC: presence of red blood cells (RBCs), white blood cells (WBCs) are few, excess of platelets
Urinalysis: Specific Gravity (SG) –1.040, no protein, bilirubin is not present
Special Tests Whiff test – strong fishy odor, Oligonucleotide probe – high levels of Gardnerella vaginalih
ASSESSMENTFINDINGSANDPLAN
  • Differential Diagnoses:
    1. ICD-10Code:Bacterial Vaginosis N 76.0 Main
    2. ICD-10 Code: Vaginal Trichomoniasis
    3. ICD-10Code: Vagina Candidiasis

Presumptive Diagnosis: Primary Dysmenorrhea and or / Bacterial Vaginosis. Plan

Considering the above patient assessment and lab tests, it is possible to suggest that the patient has bacterial vaginosis (Hemalatha, Ramalaxmi, Swetha, Balakrishna, & Mastromarino, 2013). For the mentioned disease, one of the best practices is to perform local therapeutic interventions. A good curative effect is indicated for drugs from the group of nitroimidazoles, including metronidazole, trichopolum, metro girl, etc., which are to be prescribed intravaginally in the form of tablets, tampons, or candles (Thulkar, Kriplani, & Agarwal, 2012). The comparative study of the efficacy of topical probiotics was carried out recently. Since there were no significant differences in the results of treatment in patients who received or did not receive these drugs, they are currently not recommended for the treatment of bacterial vaginosis (Mastromarino, Vitali, & Mosca, 2013). The pivotal aim of the treatment plan is to reduce the severity of clinical symptoms, normalize laboratory indicators, and prevent the development of possible complications.

Education

Consistent with the recent study by Yzeiraj-Kalemaj, Shpata, Vyshka, and Manaj (2013), it is safe to assume that education is critical to bacterial vaginosis treatment. To prevent this disease in the future and treat it, it is essential to follow the rules of hygiene. It is recommended not to wear tight underwear that disrupts blood circulation in the pelvic organs and leads to changes in the composition of the vaginal microflora (Huppert et al., 2012). It is better to replace synthetic linen and underwear with cotton.

Follow-Up

Laboratory control of the effectiveness of the therapy should be performed immediately after the isotropic treatment. In particular, with microscopy of vaginal smears stained by Gram, it is necessary to state the degree of eradication of microorganisms associated with bacterial vaginosis, while sowing vaginal discharge to identify cases of facultatively anaerobic and conditionally pathogenic microorganisms. When bacterial vaginosis comes with urogenital chlamydia and / or mycoplasmosis, laboratory testing should be repeated three weeks after the end of the therapy (Gallo et al., 2012). If symptoms of dysmenorrhea or bacterial vaginosis occur, the patient should contact a gynecologist to exclude a possible gynecological or other pathology. The patient is to be advised of the adverse effects of bacterial vaginosis and recommended to have a regular gynecological examination. With timely diagnosis and adequate treatment of bacterial vaginosis, the prognosis is usually favorable.

Self Assessment

The key methods of self-diagnosing of dysmenorrhea and bacterial vaginosis are complaints of the patient for characteristic painful sensations (Fethers et al., 2012). A visit to the doctor is necessary if a woman regularly notices unusually abundant secretions. They may be uniform, foamy or viscous, gray-white, or yellowish-green in color and have an unpleasant smell of fish. If secretions are evenly distributed across the walls of the vagina and intensify after sexual intercourse as well as before and after menstruation, it may be signs of the disease (Fethers et al., 2012). In some cases, it also causes itching, burning, and pain in the lower abdomen. Moreover, in some women, bacterial vaginosis can be completely asymptomatic. To test themselves and diagnose bacterial vaginosis at home, women who regularly monitor their health can try a new diagnostic test pad for self-diagnosis of the pH level of vaginal discharge. The mechanism of the test is based on the determination of the change in pH level and the buffer capacity of vaginal secretions. It is critical to remember that timely diagnosis and early self-assessment ensure proper and effective treatment.

References

Fethers, K., Twin, J., Fairley, C. K., Fowkes, F. J., Garland, S. M., Fehler, G.,… Bradshaw, C. S. (2012). Bacterial vaginosis (BV) candidate bacteria: Associations with BV and behavioural practices in sexually-experienced and inexperienced women. PLoS One, 7(2), 1-7.

Gallo, M. F., Macaluso, M., Warner, L., Fleenor, M. E., Hook, E. W., Brill, I., & Weaver, M. A. (2012). Bacterial vaginosis, gonorrhea, and chlamydial infection among women attending a sexually transmitted disease clinic: A longitudinal analysis of possible causal links. Annals of Epidemiology, 22(3), 213-220.

Hemalatha, R., Ramalaxmi, B. A., Swetha, E., Balakrishna, N., & Mastromarino, P. (2013). Evaluation of vaginal pH for detection of bacterial vaginosis. The Indian Journal of Medical Research, 138(3), 354-359.

Huppert, J. S., Hesse, E. A., Bernard, M. C., Bates, J. R., Gaydos, C. A., & Kahn, J. A. (2012). Accuracy and trust of self-testing for bacterial vaginosis. Journal of Adolescent Health, 51(4), 400-405.

Mastromarino, P., Vitali, B., & Mosca, L. (2013). Bacterial vaginosis: A review on clinical trials with probiotics. New Microbiol, 36(3), 229-238.

Thulkar, J., Kriplani, A., & Agarwal, N. (2012). A comparative study of oral single dose of metronidazole, tinidazole, secnidazole and ornidazole in bacterial vaginosis. Indian Journal of Pharmacology, 44(2), 243- 258.

Yzeiraj-Kalemaj, L., Shpata, V., Vyshka, G., & Manaj, A. (2013). Bacterial vaginosis, educational level of pregnant women, and preterm birth: A case-control study. ISRN Infectious Diseases, 2(1), 1-4.