L.R. is a 28-year-old female patient who was evaluated at the clinic because she presented thin and white vaginal discharged which was increased after sexual intercourse.
The vaginal discharge has a pH of 5.2, positive KOH test and clue cells (more than 40% of epithelial cells) on microscopic examination.
Questions to answer:
List your Primary diagnosis with ICD 10 number.
Discuss three differential diagnoses for AUB with ICD 10 numbers for each.
Discuss patient education.
Develop the management plan (pharmacological and nonpharmacological).
An effective health assessment incorporates not only physiological parameters; please suggest other parameters that should be considered and included on health assessments to reach maximal health potential on individuals.
Name the different family developmental stages and give examples of each one.
Describe family structure and function and the relationship with health care.
Trichomoniasis (ICD-10: A59.01): This is a sexually transmitted infection caused by a parasite, which can lead to a frothy, yellow-green, and foul-smelling vaginal discharge. It is often accompanied by itching and can cause vaginal bleeding. The pH is typically elevated, but a positive KOH test and clue cells are not characteristic.
Candidiasis (ICD-10: B37.3): Also known as a yeast infection, this is caused by an overgrowth of Candida fungus. The discharge is typically thick, white, and "cottage cheese-like," often with severe itching and redness. The vaginal pH is usually normal (<4.5), and a positive KOH test would show budding yeast and pseudohyphae, not clue cells.
Patient Education
I would educate L.R. about the following key points:
What it is: Explain that BV is a common bacterial imbalance in the vagina, not a sexually transmitted infection, but it can be triggered by sexual activity.
Cause: Clarify that BV is not caused by poor hygiene, but by a disruption in the normal vaginal flora.
Prevention: Advise her to avoid douching, bubble baths, and scented products that can disrupt the vaginal environment. Suggest using condoms to prevent future episodes, as semen's alkaline pH can trigger symptoms.
Treatment: Explain the importance of completing the full course of prescribed medication, even if symptoms improve quickly, to prevent recurrence.
Partner Treatment: Reassure her that male partners do not need to be treated, but female partners should be evaluated if they have symptoms.
Management Plan
Pharmacological: Prescribe Metronidazole 500 mg tablets, to be taken twice a day for 7 days. Alternatively, Metronidazole 0.75% vaginal gel can be prescribed, to be used once daily for 5 days. For her partner, no treatment is needed as per the CDC guidelines.
Nonpharmacological:
Lifestyle Modifications: Advise L.R. to avoid douching and perfumed hygiene products.
Clothing: Suggest wearing cotton underwear and loose-fitting clothing to allow air circulation and reduce moisture.
Sample Answer
Primary Diagnosis and Differential Diagnoses
Primary Diagnosis: Bacterial Vaginosis (BV), ICD-10 code: N76.0. This is the most likely diagnosis based on the clinical presentation and laboratory findings. The thin, white discharge, increased after intercourse, a pH greater than 4.5 (in this case, 5.2), and the presence of clue cells are all hallmark signs of BV.
Differential Diagnoses for Abnormal Uterine Bleeding (AUB):
Cervicitis (ICD-10: N72): This is an inflammation of the cervix, often caused by sexually transmitted infections (STIs) like chlamydia or gonorrhea. While it can cause abnormal bleeding or discharge, the discharge is typically purulent and the clinical presentation may include pelvic pain or spotting.