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Case Presentation

Case Presentation. Kimberly Henry State University of New York Institute of Technology February 12, 2014. RO is a single 22 year old African American female presenting to the OB/GYN office to establish care on 02/06/2014

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Case Presentation

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  1. Case Presentation Kimberly Henry State University of New York Institute of Technology February 12, 2014

  2. RO is a single 22 year old African American female presenting to the OB/GYN office to establish care on 02/06/2014 CC: Pt states “I am here for my annual exam and I want to talk about my infections” HPI: RO has had pelvic pain and discharge which comes and goes for about 1 month. Pain is not related to ovulation or menses. Menses is irregular, light flow and occurs every other month. LMP 01/03/2014. RO has not tried any OTC products for pain relief. Admits to recurrent vaginal infections (>3 per year). Discharge is foul smelling and clear to white in color.

  3. Health History • Medical Illnesses: Denies • Psychiatric Illnesses: Denies • Injuries/Accidents: Denies • Surgeries: Denies • Hospitalizations: NSVD 2012, Crouse Hospital Syracuse, NY 40 weeks, male 6#14oz • Transfusions: Denies, but agrees to • Blood Type: A+ • Childhood illnesses: Denies • Immunizations: Up to date for age, did not receive Gardisil series, does not want influenza vaccine • Allergies: Denies medication, environmental, food or latex allergy • Current Medications: none • Family history: Father, alive age 52, Renal disease Mother, alive 49, HTN Maternal aunt, alive, 45, breast CA (brcaunk)

  4. RO resides in a 2 family home with her 18 month old son. She has adequate access to telephone, refrigeration, heat and water. RO is high school educated and is employed outside the home in retail. Home does not contain firearms or pets. Water is fluorinated. Home does contain working smoke detectors. RO uses seat belts while in a moving vehicle. RO denies any cultural or spiritual concerns at this visit. RO was born in PA and she denies any tobacco or recreational drug use. Admits to occasional alcohol consumption. Admits to occasional caffeine intake. Admits to a moderate amount of exercise weekly. Currently is not sexually active.

  5. Review of Systems Denies fevers, chills, fatigue, night sweats, hot/cold intolerances, unintentional weight gain or loss GYN: G1 P1 T1P0A0L1 Age of menarche is 12. Pre-menopausal. LMP 01/03/2014. Last Pap exam 2012. Menses are irregular, light flow. Admits to vaginal itching, vaginal discharge, foul odor. Admits to pelvic pain x 1 month. Denies hx of abnormal paps. Denies breast lumps, breast pain, and nipple discharge. Denies hx of STD’s. Denies douching. Admits to recurrent vaginal infections

  6. GU: Denies dysuria, hematuria, polyuria, incontinence, CVA tenderness/pain, hx of stones or infections GI: Denies food intolerances, dysphagia, heartburn, nausea, vomiting, constipation, diarrhea, hemorrhoids, ulcers, hx of hepatitis or jaundice. Had in office sono today

  7. Physical Exam Vital signs: 108/64 RR: 14 HR 65 Temp 37.2 Height 62” Weight 146 lbs BMI 26.7 Sono report: Showed endometrial thickness of 7.2mm, no fluid in the cul de sac, and a possible polyp in EC. Left ovary 3.0cm x 1.8cm x 2.2cm with no evidence of a mass or cyst. Right ovary 3.3cm x 2.1cm x 1.9cm with a 3.6cm simple cyst noted. Color flow visualized in both ovaries General: Well developed, well nourished, well groomed 22 yr old, AOx3, in no apparent distress. Pleasant and cooperative.

  8. Skin: Warm, dry, intact. Absent of pallor or cyanosis. No impressive skin lesions observed Neck: Symmetrical, trachea midline, supple, absent of adenopathy or thyromegaly. ROM intact CV/PV: RRR, S1 and S2 intact, absent of murmurs, rubs, or gallops. Capillary refill <3 seconds. Absent of bruits. Absent of peripheral edema. +2 peripheral pulses Respiratory: Symmetrical, breath sounds equal bilaterally and clear. Absent of pain on inspiration/expiration

  9. Abd: Soft, symmetrical, +bowel sounds present in the 4 quadrants, +striae, absent of other scars or lesions. + discomfort RLQ no other guarding or pain on palpation. Absent of organomegaly or palpable masses MS: Ambulates without assistance, able to get into lithotomy unassisted. Full ROM of all extremities and back, absent of skeletal tenderness and joint deformities. Neuro: Appropriate affect, speech intact, oriented to person, place, and time. Absent from preoccupation of abnormal thoughts. Breast: Symmetrical, nipples unremarkable, absent of dimpling, masses, lesions, or discharge. Absent of axillary adenopathy and breast tenderness

  10. GU: External: Public hair normally distributed. Clitoris and labia unremarkable. Normal glands. Perineum and perianal area unremarkable Internal: Urethra unremarkable and absent of discharge. Strong foul odor detected, vaginal mucosa contains thin white discharge. Cervix normal to inspection and palpation without cervical motion tenderness. Uterus palpable, anteverted, normal in size, absent of uterine and adnexal tenderness. Ovaries palpable, R cyst palpable and tender. Left ovary normal to palpation

  11. Any thoughts on the DDX?

  12. Differential Diagnoses • Vaginitis caused by BV, Yeast, or Trichomoniasis • Cervicitis from GC/Chlamydia • Normal cervical mucus • UTI • Contact/Allergic Dermatitis • Lichen planus • Lichen Simplex Chronicus

  13. Vagina’s are happiest when their Ph is around 4.0-4.5 Keeping your vagina within these parameters is not easy Semen~ ph 7.1-8.0 Blood~ ph 7.4 This is why most symptomatic women will complain of BV after sexual intercourse or menses

  14. Vaginal Cultures: Affirm One Swab (more expensive testing, but helps with finding causative agent to recurrent BV

  15. 2010 CDC Treatment guideline for BV Metronidazole (Flagyl) 500mg PO BID for 7 days OR Flagyl gel 1 5gm applicator PV QHS for 5 days OR Clindamycin vag cream 1 applicator PV Q HS for 7 days Alternatives: Tinidazole (Tindamax) 2gm PO Q Day for 2 days OR Tindazole 1gm PO Q Day for 5 days OR Clindamycin Ovules 100mg PV QHS for 3 days

  16. Recurrent BV Long term suppressive therapy may be needed in symptomatic woman with more than 3 episodes in a 12 month period Some woman go through a cyclic pattern of treating the BV but then developing Candida from changing the vaginal ph No consistent guidelines on long term therapy UptoDate reports using Vaginal Metrogel or Oral Flagyl for 7 days followed by Metrogel 2x week for four to six months. Improved results occurred by adding vaginal boric acid 600mg at bedtime for 21 days after initiation of 7 day Metrogel or Flagyl

  17. Patient Education • The best way to eradicate the offending agent, one should abstain from sexual intercourse during therapy • Thoroughly clean all sex toys which may harbor bacteria • Probiotics may help with ph balance, but not proven

  18. References: • Baldor, R. A., Golding, J., & Grimes, J. A. (2014). The 5-minute clinical consult 2014 (22nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. • Sobel, J. (2014). Bacterial Vaginosis. In D.S.Basow (Ed), UpToDate. Retrieved from http://www.uptodate.com

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