Patient Case Study: Vaginal Gradient

J.M is a 21-year old Caucasian female presented to the office with complaints of vaginal discharge of white, itchy, fishy odor that is fierce after sex for about 1.5 weeks. The patient states, the young man is her first relationship for a year. J.M states they sometimes use a condom, and she experiences pain during sexual intercourse at times.
Assessment
V/S: BP-110/73 Left Arm, P-76 Rate and Rhythm, R-20, T-97.9 Orally, Wt-125lbs, White vaginal discharge is contributed to STI. The patient had a bimanual examination of the vagina and cervix along with a Pap smear, and cytology. A positive whiff test (fishy odor), and wet smear revealed numerous white blood cells counts on saline. To differentiate between bacterial vaginosis, trichomonas’s,
“Bacterial vaginosis is common in women with PID and may facilitate the ascent of microorganisms into the upper genital tract” (Soper, 2010) (Schuiling et al., 2013). The treatment regimen may differ according to the infectious organism using some broad-spectrum antibiotic. Antibiotic therapy requires two medication to combat the infection, and effective treatment felt within 72hours. If a therapeutic effect is unsuccessful within the time frame, reevaluation of PID is necessary whether outpatient or inpatient. “The most important action a clinician can take is preventative counseling” (Schuiling et al., 2013). As a practitioner, educating the patient, and partner about safe sex by using barrier contraceptive methods. Routine screening for women with risk factor asymptomatic to chlamydial and gonorrheal infections. A pelvic examination should be done in the acute phase, and close monitoring of patient with IUD. Instruct the patient to rest and consume a nutritional diet. The practitioner should emphasize completing the prescribe medication, and report difficulty in obtaining the drug. The women sex partner need evaluation and treatment, and the couple should avoid sexual contact until cleared by the