Patient Case: Unprotected Sexual Intercourses

Name: A.Z. S O A P Time:12.10 p.m.
Date:9/26/2017 Age:19 y/o Sex: F
SUBJECTIVE
CC:
I think I may be exposed to HIV.”
HPI: Mrs. A.Z. presents to the office complaining of poor sleep last few weeks because she has sexual intercourse with two different partners without protection 6 weeks ago in a party. She never meets them before. She feels anxious because she does not know the persons and cannot contact them. At that time, she had many drinks and cannot remember very well but she thinks that they probably used some kind of recreational drug. The next day she took plan B to avoid pregnancy. Denies urinary burning vaginal discharge, sore throat fever or rash. She wants to know if she can be tested for HIV. Since last weeks she is worried about HIV and dos not sleep well. She does not want to comment her worries to anyone.
Medications:
B one month ago
PMH

Allergies: The patient states that she does not suffer from any environmental, food, or drugs allergies

Medication Intolerances:
There is no medical data about medication intolerances.
Chronic Illnesses/Major trauma
Denies Mayor Illness or trauma
OB Gyn Menarche 11 y/o G0
LMP last week Regular 3 days

Family History
Father is alive having diabetes. Negative for cancer, heart disease, hypertension, tuberculosis, other medical illnesses.
Mother is alive having hypertension. Negative for cancer, heart disease, tuberculosis, other medical illnesses
Social History
The patient is socially active. She is in college, practices tennis in weekends. She does not use tobacco or drugs, she drinks heavy at weekends She only had 3 sexual partners last 6 months. Normally uses condoms. She has good family relations She works part time at college.
ROS
General Cardiovascular
Last few weeks she feels no much energy poor sleep, the patient has no problems with weight. She denies weight loss/gain, fever, andnightsweats. The patient 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,delayedhealing,bruising,bleedingorskindiscolorations. The patient denies any changes in moles.

Respiratory

There are no signs of problems. The patient deniesshortnessofbreath, cough,congestion,wheezing,hemoptysis,dyspnea,pneumonia.There is also no tuberculosis related symptoms history.

Eyes

There are no reported problems with sight. The patient denies blurring, visual changes of anykind.She does not visit ophthalmologists regularly because does not feel the need for it.

Gastrointestinal

She has no complaints of gastrointestinal system. The patient denies symptoms related to hepatitis, hemorrhoids, eating disorders, ulcers, blacktarry stools.

Ears

The patients hearing is fine. She has never experienced ear pain, hearing loss, ringing in ears, etc. There are no signs of ear traumas.

Genitourinary/Gynecological

Denies pelvic pain urinary burning or urethral discharge. No history of STDs or vaginal or urinary infections.

Nose/Mouth/Throat

The patient does not have any oral cavitys diseases. She denies a sorethroat, discharge,dysphagia,nosebleeds,dentaldisease,hoarseness.

Musculoskeletal

The musculoskeletal development is normal. No signs of dystrophy. She denies trauma, backpain, hippain.Deniesfracture.The examination does not demonstrate any visible problems in the sphere.

Breast

There are no signs of breast cancer. The patient denies lumps, bumps or changes.There is no breast cancer history in the family.

Neurological

Monthly headaches during her menses. A severe headache. She does not experience spontaneous episodes of weakness, memory loss, mental problems, etc.

Heme/Lymph/Endo

She denies blood transfusion. No extreme sweating, alterations in her appetite, lymphatic nodes enlargement

Psychiatric

The patient feels anxiety after she had sexual intercourse without protection, she takes long time to fall sleep Denies depression, , suicidal attempts, etc.

OBJECTIVE
Weight:131lbs BMI: 21.8 Temp:97.7tympanic BP:100/70rightarmsitting
Height:5’5” Pulse:86 x min Resp:14 x min. Oxy Sat 98%
General Appearance

Female not in distress cooperative answers willingly and appropriately.

Skin

The patients skin is of normal color. It 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 in accordance with the sex character. No tenderness. No signs of major traumas.

The patients eyes demonstrate no signs of significant health problems. 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 problems. Mucosa is fine and pink. There are no deviations.

Neck: No nodes
Pharynx is pink. Oral mucosa is fine. Problems with occlusion that should be corrected

Teeth are fine. There are no nodules. Finally, no lymphadenopathy or thyromegaly are discovered. Oral mucosa is moist and pale pink

Cardiovascular

No extra sounds are discovered during the patients investigation. The rate and rhythm are regular. Capillary refill – 1,9 seconds. There is no edema.

Respiratory

The patients chest wall is symmetric. 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. There are no signs of visible health problems.

Breast
Breast exam proves the absence of health problems. No signs of breast cancer. No calcifications. The overall state could be described as normal.
Genitourinary

External exam: Vulva is pink, without any traumas or signs of damage. There is no discharge on the walls. Pelvic examination shows vaginal mucosa pink, no secretions, os closed. bimanual exam shows uterus anteverted no mases non tender.
Adnexa is palpable. Rectal exam demonstrates the absence of pain, mases 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. Balance is stable. No visible neurologic diseases.

Psychiatric

The patient maintains the eye contact. 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
HIV Screening Tests
Antigen/antibody test – negative for both HIV antibodies and antigens. Antigen p24 is not found (“HIV testing,” 2017).
Urine test – no HIV antibodies found.
STDs tests
Blood test – no STDs discovered.
Urine test – no STDs discovered.
Vaginal swab – no signs of STDs.
Cervical, urethral swabs – negative for STDs (Healthline Editorial Team, 2016).
Special Tests
NATs test – in case the patient insists on the additional investigation (“Testing,” 2017).
ASSESSMENTFINDINGSANDPLAN
  • Differential Diagnoses:
    1. ICD-10 Code: №B20 – Human Immunodeficiency virus (HIV)
    2. ICD-10 Code: №A64 – Unspecified sexually transmitted disease
    3. ICD-10 Code: №F41.9 – Anxiety disorder, unspecified
The patient is afraid of having HIV or another sexually transmitted disease because of the unprotected sexual intercourse with two partners during the party. The main symptoms are anxiety, sleeping disorder, fear. There are no other complaints or symptoms. For this reason, the three diagnoses could be applied to the case.

These are HIV, STDs, or anxiety disorder preconditioned by the fear of contagion. Considering the fact that the patient denies having other health problems, it is crucial to use specific tests either to prove or to refute the outlined diagnoses. The patient usually uses condoms; she had only 3 sexual partners. She studies at college and is socially active. The patient has good relations with relatives and friends. Denies vaginal or urinal infections. In the course of the examination, no signs of HIV or STDs were discovered. That is why anxiety disorder remains the main presumptive diagnosis.

To prove the final diagnosis, it is crucial to exclude HIV and STDs from the list. For this reason, HIV screening tests like antigen/antibody and urine ones should be prescribed. They will indicate the presence or absence of the disease. Moreover, the blood test to discover STDs is needed. To consider all risk factors, vaginal, cervical, and urethral swabs investigation should be prescribed. In case all tests are negative for HIV and STDs, the unspecified anxiety could be diagnosed.

Presumptive Diagnosis: Anxiety Disorder

Plan:

  • Treatment
    • Exclude HIV and STDs from the list.
    • Demonstrate the absence of threat to the patients health.
    • Consultation with a psychologist to treat anxiety. Yoga, physical exercises.
    • Sedative (Xanax) to treat the sleeping disorder (Bystrinsky, Khalsa, Cameron, & Schiffman, 2013).

Education

The patient should be explained that her behavior is extremely dangerous for her health. HIV and other STDs could have a devastating impact on the quality of peoples lives. Unprotected sexual intercourse with an unknown partner is strongly prohibited because of the high risk of contagion (“Unprotected sex and HIV,” 2017). The patient should be educated to use condoms every time she plans sexual intercourse. Additionally, drug use is prohibited (Remy et al., 2013). Finally, casual sex increases chances for HIV or STDs contagion (Ford, Barnes, Rompalo, & Hook, 2013). For this reason, long-term relations could minimize risks. The nature of HIV should be explained to the patient to demonstrate its dangerous character and the outstanding impact on the quality of peoples lives.

Follow-Up

  • The patient should visit a psychologist to treat anxiety disorder
  • The state of the patient should be examined in a month. Additional HIV screening tests should be prescribed to guarantee the absence of the disease.
  • The psychological state of the patient should be monitored.

Self-Assessment

The given case demonstrates a great danger that comes from unprotected sexual intercourses. HIV and STDs become a topical problem of the modern society. For this reason, it is crucial to educate young people who comprise the main risk group about the necessity of using condoms. Moreover, promiscuous sexual activity increases the risk of contagion significantly. The case provides the opportunity to acquire the information about the main tests that are used to determine HIV or STD. Moreover, it demonstrates the importance of educating patients about the nature of these diseases and their impact on the health of a person.

References

Bystrinsky, A., Khalsa, S., Cameron, M., & Schiffman, J. (2013). Current diagnosis and treatment of anxiety disorders. Pharmacy and Therapies, 38(1), 41-44. Web.

Ford, J., Barnes, R., Rompalo, A., & Hook, E. (2013). Sexual health training and education in the U.S. Public Health Reports, 128(1), 96-101. Web.

Healthline Editorial Team. (2016). STD testing: Who should be tested and what’s involved. Web.

HIV testing. (2017). Web.

Remy, L., Navarez, J., Sordi, A., Guimaraes, L., Diemen, L., Surratt, H.,… Pechansky, F. (2013). Correlates of unprotected sex in a sample of young club drug users. Clinics, 68(11), 1384-1391. Web.

Testing. (2017). Web.

Unprotected sex and HIV. (2017). Web.