sample patient case report with vaginal discharge due toti

What is a discharge summary report?

Discharge summary reports play a vital role in informing the immediate family about the patient’s condition during the duration of his or her stay in the hospital. It has to provide true details about the patient in observance of the hospital’s protocols. Following the right contents would make it concise and accurate.

Can a vaginal discharge be sent to a lab?

In most local primary care settings, an in-house microscope may not be available, and specimens of vaginal discharge for investigations must be sent to an external laboratory. If a lower genital tract infection is suspected, point-of-care testing can aid diagnosis based on the pH levels of the discharge.

What are the non-infectious causes of vaginal discharge?

Non-infectious causes include atrophic vaginitis, contact dermatitis due to allergic or irritant causes, foreign body vaginitis (e.g. retained tampon or condom), cervical polyps, fistulas and genital tumours (e.g. tumours of the vulva, vagina, cervix, fallopian tube and endometrium).(3) A diagnostic aid to vaginal discharge

Is it normal to have vaginal discharge in Singapore?

Vaginal discharge may be a normal physiologic occurrence or a pathological manifestation. In Singapore, we are likely to be underdetecting the number of women with abnormal vaginal discharge in primary care, as it is often viewed as a taboo complaint or embarrassing in Asian cultures.(2)

What are the major causes of abnormal vaginal discharges?

The major causes of abnormal vaginal discharge are either vaginal or cervical infections. Causes of vaginal infections are Gardnerella vaginalis, Trichomonas vaginalis, and Candida albicans. Primary cervical infections causing vaginal discharge are Neisseria gonorrhoeae, Chlamydia trachomatis, and Herpes simplex.

Is vaginal discharge a diagnosis?

How is vaginal discharge diagnosed? If your vaginal discharge increases, changes color or odor, or is suddenly itchy or irritated, see your doctor. You may have a yeast infection, bacterial vaginosis, or trichomoniasis. Your doctor will need to examine you to make a diagnosis.

What is physiological vaginal discharge?

Discharge from the vagina is common and often normal in women. Sometimes this is called a 'physiological discharge'. Physiological discharge contains cleansing bacteria (called lactobacilli) which help to prevent some infections.

What are discharge issues?

A discharge from the vagina may occur normally or may result from inflammation of the vagina (vaginitis) due to an infection. The genital area (vulva)—the area around the opening of the vagina—may also be inflamed. Depending on the cause of the discharge, other symptoms are often also present.

How do you evaluate vaginal discharge?

The use of narrow-spectrum pH paper as a point-of-care tool, if available, can help with the assessment of vaginal infection. High vaginal swabs for microscopy (wet mount and Gram stain), culture and sensitivity should be considered in those with chronic or recurrent presentations.

What microbes can cause vaginal discharge?

Bacterial vaginosis (BV) is a vaginal infection caused by bacteria. It is the most common cause of abnormal vaginal discharge that occurs in reproductive-age women (women who have not gone through menopause yet). Bacterial vaginosis may cause a "fishy" odor and cause vaginal irritation in some women.

What causes a lot of discharge?

Reasons for excess vaginal discharge include taking antibiotics, being pregnant, diabetes, birth control pills, stress, as well as infections such as yeast infections and bacterial vaginosis. Your vagina and cervix contain glands that produce a mucus called vaginal discharge.

Where does vaginal discharge come from?

Vaginal discharge is made by the skin cells of the vagina and cervix under the influence of the female hormone, estrogen. Women who are menopausal normally have minimal vaginal discharge as a result of lower levels of estrogen.

How much vaginal discharge is normal?

Premenopausal women (time menses starts until menopause) normally have approximately one-half to one teaspoon (2 to 5 mL) of white or clear thick, mucous-like, and mostly odorless vaginal discharge every day. The amount can vary at different times throughout the menstrual cycle-related to hormonal fluctuations.

What is TV in a patient?

Our patient was diagnosed with Trichomonas vaginalis (TV). TV is a flagellated parasitic protozoan for which humans are the only known host. It is 10-20 um long and 2-14 um wide with multiple flagella projecting from the anterior and posterior sides. It has a single trophozoite stage and does not survive well outside of its host. TV is a predatory obligate parasite that eats bacteria, vaginal epithelial cells, and red blood cells. It uses fermentative metabolism to produce the carbohydrates needed for fuel. TV is a sexually transmitted disease; however, because it is not reportable to local health departments, the true epidemiologic incidence rate is unknown. Its prevalence is highly variable by population and location. For example, some studies cite a prevalence of 3.1% of American pre-menopausal women (2.3% of adolescents) [1], while in certain high-risk populations the rate might be as high as 47% [2]. Most affected patients are asymptomatic; about a third of females become symptomatic within six months of infection. Symptoms for females include vulvar and vaginal irritation and itching, pain with urination and a diffuse, malodorous, yellow-green vaginal discharge. The cervix becomes reddened in a punctuated fashion causing the well-known strawberry cervix seen on colposcopy. In males, urethritis can develop. TV is often diagnosed via wet mount microscopy, where the protozoa can be seen moving around (Video 1). However, the sensitivity is relatively low, especially among males. Detection by nucleic acid probe from urine, endocervical, and vaginal swabs are considered more sensitive. TV can also be incidentally discovered on Pap tests (Figures 1 and 2). Treatment typically consists of a single dose of metronidazole [1,2]. It is critical that partners be treated as well, because otherwise reinfection may occur.

What does TV eat?

TV is a predatory obligate parasite that eats bacteria, vaginal epithelial cells, and red blood cells. It uses fermentative metabolism to produce the carbohydrates needed for fuel.

How long does it take for a woman to become asymptomatic?

Most affected patients are asymptomatic; about a third of females become symptomatic within six months of infection. Symptoms for females include vulvar and vaginal irritation and itching, pain with urination and a diffuse, malodorous, yellow-green vaginal discharge.

Is TV sensitive to Pap?

Detection by nucleic acid probe from urine, endocervical, and vaginal swabs are considered more sensitive. TV can also be incidentally discovered on Pap tests (Figures 1 and 2). Treatment typically consists of a single dose of metronidazole [1,2].

What are the most common causes of vaginal discharge?

Clinical features associated with the three most common causes of vaginal discharge.(5,9) Open in a separate window. Cervicitis is another important cause of vaginal discharge, with Chlamydia trachomatisand Neisseria gonorrhoeaebeing the most common pathogens isolated.

What is a high vaginal swab?

A high vaginal swab for microscopy (wet mount and Gram stain), culture and sensitivity should be considered to confirm the diagnosis if the woman has the following characteristics: chronic or recurrent symptoms (Box 1) , symptoms that are not characteristic of VVC or BV, postpartum state, post termination of pregnancy, and post instrumentation.(5) In the latter three, these women should be referred back to their obstetrics and gynaecology (O&G) specialist.

How many primary care visits are there for vaginal discharge?

Vaginal complaints account for approximately 10 million primary care visits annually in the United States alone.(1) It is the most common gynaecological complaint seen by primary care doctors, yet rates of misdiagnosis are high. Vaginal discharge may be a normal physiologic occurrence or a pathological manifestation. In Singapore, we are likely to be underdetecting the number of women with abnormal vaginal discharge in primary care, as it is often viewed as a taboo complaint or embarrassing in Asian cultures.(2)

What is normal discharge?

Normal physiological discharge changes with the menstrual cycle. The character of the discharge tends to be clearer with a stretchable consistency around ovulation, then may be thicker and slightly yellow during the luteal phase. Normal healthy discharge should not be associated with symptoms such as itching, redness and swelling, and does not have a strong odour.(3) Vaginal discharge can increase during higher oestrogen states, such as ovulation, the luteal phase, puberty and pregnancy, and with oestrogen-based therapies such as combined hormonal contraception and hormone-replacement therapies. Normal vaginal discharge is found in 10% of those who present with vaginal discharge.(4)

What is the recurrence rate of VVC?

This group is asymptomatic in between discrete attacks. The estimated recurrence rate in the literature is 5% for VVC infection (commonly defined as four or more culture-proven episodes in a year),(9,11) 12.5%–18.5% in TV(12) and up to 50% for BV (also defined as three or more confirmed episodes using Amsel’s criteria in a few studies) within a one-year period.(13) However, these statistics have an inherent limitation due to a few reasons: varying definitions of what recurrence means, use of over-the-counter medications and frequent empirical treatment of vaginal infections without diagnostic confirmation by physicians.

How old is Miss Lim?

Miss Lim, a 26-year-old business executive, came to your clinic for vaginal discharge of over one week’s duration. A month ago, she had been treated with one dose of oral fluconazole for a vaginal yeast infection and had seen symptomatic improvement. On this occasion, she reported the same symptoms of itch and vaginal discharge. This was her third episode in six months. She was sexually active with one stable male partner. She thought the yeast infection had recurred and requested the same treatment.

What is inflammatory vaginitis?

Inflammatory vaginitis is often associated with physical examination findings such as erythema and oedema and the presence of polymorphonuclear neutrophils (PMNs) on microscopic examination. This is most commonly seen in TV and VVC, but can also be found in atrophic vaginitis, desquamative inflammatory vaginitis and multimucosal erosive disease (e.g. erosive lichen planus and pemphigus vulgaris). On the other hand, non-inflammatory conditions do not have the aforementioned signs and are not associated with PMNs on microscopy. BV is the most common example.(7)

What is the condition of a 59 year old woman?

This is a 59-year-old, right-handed woman with a history of hypertension, schizophrenia, and a fallopian ovarian tumor resection surgically and with radiotherapy treatment, who presented to the emergency room with a four-hour history of difficulty talking, and numbness and weakness on the right side. She was in her usual state of health until early the morning of admission when she woke up and noted numbness on her right side. Her numbness was associated with weakness as well as difficulty speaking, with no associated headache, chest pain, fever, chills, double vision difficulty swallowing, or palpitations. She reported having a similar incident about one month prior to admission when she was seen in the emergency room, but at that time, her symptoms resolve while in the emergency room. CT scan at that time showed bilateral basal ganglion infarcts. Carotid duplex then showed minimal plaque, rig ht greater than left, with no hemodynamic stenosis. At that time, she was sent home on aspirin 1 q.d. which she has been taking except for the day prior to admission when she missed her dose.

Why was a 36 year old woman admitted to the hospital as an outpatient for D&C?

REASON FOR ADMISSION: This is a 36-year-old female who was admitted to the hospital as an outpatient for D&C because the patient had been having irregular vaginal bleeding between her menstruations.

How long after discharge can you return to the neurology clinic?

2. Return to the neurology clinic about one month after discharge.

Why is discharge summary important?

Importance of Discharge Summary 1 It helps improve the discharge process – individuals assigned in the transition of a patient would always look for ways to improve the discharge process. this includes the discharge planning, enlisting of medications and follow-up appointments. 2 It serves as the mode of communication between the hospital care team and aftercare.

What happens when you leave a hospital?

When you leave the hospital after a treatment, you will be issued a patient discharge summary. This is to be written and signed by the attending physician together with the necessary details of the patient during his or her stay.

What is discharge summary?

A discharge summary is a type of letter written by physicians to record the reason why you got admitted, the results of the tests, the list of your medication and the follow-ups that you needed. This is considered essential especially when you are going to transfer information to the primary physician assigned to a particular patient. This should contain relevant information pertaining to the patient’s condition.

Why do patients have to be accompanied by medical personnel?

The patient will be accompanied by a medical personnel because it is part of the hospital’s protocol. Some medical personnel would still assess your condition despite being discharged.

When can a hospital discharge a patient?

A hospital will be able to discharge a patient when he or she no longer needs inpatient treatments. They can also discharge you if they are to transfer you to another facility.

What is a patient case study?

Writing Your Patient Case Study. Since patient case studies are generally descriptive, they are under the a phenomenological principle. This means that subjectivity is entertained and allowed in research design. The medical scenarios are open to the researcher’s interpretation and input of insights.

What is case study in medical?

It is a well-established empirical research approach that illuminates a stand-out case of a subject or a group of subjects. In the end, it seeks to introduce new information for the understanding of the nature of a disease or medical condition in the context of someone who has lived it. Patient case studies make a difference in the medical arena by reporting clinical interactions that can improve medical practices, suggest new health projects, as well as provide a new research direction. By looking at an event as it exists in the natural setting, case studies shed understanding on a complex medical phenomenon.

What is a case study?

Case studies are a qualitative research method that offers a complete and in-depth look into some of the situations that baffled medical science. They document the cases that escape the ordinary in a hospital that has seen a manifold of plights. They serve as cautionary tales of the intricacy in dealing with human health.

How do case studies make a difference in the medical arena?

Patient case studies make a difference in the medical arena by reporting clinical interactions that can improve medical practices, suggest new health projects, as well as provide a new research direction. By looking at an event as it exists in the natural setting, case studies shed understanding on a complex medical phenomenon.

Why are case studies important?

However, case studies offer a comprehensive and exhaustive treatment on a complicated subject matter in a real-life setting. This research method lets you gain an appreciation for a concept beyond what cold, hard facts can provide. There is no single approach to science and knowledge.

Why do medical practitioners use case studies?

Medical practitioners use case studies to examine a medical condition in the context of a research question. They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. The following are case study samples and guides on case presentation.

Why should you indicate the general scope and limitation of your work?

Because you are studying a case valid only for some people as of the moment, you should indicate the general scope and limitation of your work. The scenario might be different when placed in a different context. You should be honest in reporting the information about your study. Disclose the limits of your findings.

What stitches were used for the parietal peritoneum?

Once appropriate hemostasis had been achieved and the lap and instruments counts were reported as correct, the parietal peritoneum was approximated using #0 Vicryl continuous stitch, followed by approximation of fascia using Vicryl #1 continuous stitch in two segments. The skin was approximated with #4-0 Vicryl subcuticular stitch. The patient tolerated the procedure well and returned to the recovery room in good condition with Foley draining blue-colored urine.

What clamps were used to grasp the left and right ovaries?

At this time, Babcock clamps were used to grasp the left and right ovaries, and they were removed per the patient’s request. Curved Zeppelin clamps were placed across the infundibulopelvic ligaments bilaterally and curved scissors were used to excise the specimen from the Zeppelin clamp. The pedicles were doubly ligated bilaterally with 0 Vicryl and hemostasis noted to be achieved. No other abnormalities were noted in the pelvic cavity.

What ligaments were used in the Ligasure device?

The LigaSure device was then used in a serial fashion up through the cardinal ligaments bilaterally. Finally, the uterine arteries were cross-clamped, cut, and ligated with the LigaSure device. LigaSure device was then used up through the broad ligaments superiorly and finally the uterus was rotated posteriorly. The left and right tubes were then cross-clamped and ligated with LigaSure device. The uterus was excised and submitted for pathologic evaluation.

What was removed from the patient's abdominopelvic cavity?

At this time, instruments were removed from the patient’s abdominopelvic cavity. Vaginal cuff closure and peritoneum were incorporated into one layer with 0 Vicryl suture in a continuous running interlocking fashion. Hemostasis was noted to be achieved. Foley catheter was then placed yielding clear amber urine. A vaginal packing with Premarin cream was placed to provide support during the healing process. The patient tolerated the procedure well and was taken to the recovery room in a stable condition. Sponge and needle counts were correct x3.

How to cut a right round ligament?

The right round ligament was clamped with two Kelly clamps, cut with Metzenbaum scissors and suture ligated with #0 Vicryl. The anterior leaf of the broad ligament was cut using Metzenbaum scissors. The bladder that was adherent to the anterior aspect of the uterus was gently dissected using sharp and blunt dissection and it was gently pushed down with the sponge on a stick. Two fingers were inserted through the posterior leaf of the right broad ligament. The tissue was cut with Metzenbaum scissors and it was clamped using a straight Heaney clamp. Another clamp was placed medial to this. It was cut with Metzenbaum scissors. Sutures transfixed x2 using #0 Vicryl. The right uterine artery was then skeletonized, clamped at the level of the cervical os using a curved Heaney clamp. Another clamp was placed medial to this. It was cut with the Metzenbaum scissors and suture transfixed x2 using #0 Vicryl. Similar procedure was done on the opposite side.

What was the cord cut between the clamps?

The cord was doubly clamped, cut between the clamps, and the infant was handed away to the pediatrician. Cord bloods were taken. The placenta was then manually separated. The edges of the uterine incision were then reapproximated with continuous running suture of #1 chromic catgut.

How was the Pfannenstiel incision made?

A Pfannenstiel incision was made with a clean scalpel. The incision was taken down the fascial layer with a clean second knife. The fascial layer was incised transversely to the full length of the primary incision. The underlying muscle bellies were dissected with blunt and sharp dissection. The muscle belly was split in the midline. The peritoneum was then grasped between 2 Kelly clamps and elevated. After ensuring no adherent bowel or bladder, the peritoneum was nicked between clamps. The abdominal cavity was thus entered. The bladder flap was formed with blunt and sharp dissection and then the uterus was scored in the lower uterine segment in transverse fashion, and the incision was enlarged in elliptical fashion with bandage scissors. The infant was found to be in face presentation with nuchal cord x1. Mouth and nose were suctioned prior to delivery of rest of the body. The cord was slipped over the shoulders and then the infant was delivered. It was a living female with Apgars of 8 and 9. There was meconium, but it was not thick. Cord pH was 7.30. The cord was doubly clamped, cut between the clamps, and the infant was handed away to the pediatrician. Cord bloods were taken.

History

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Examination

Questions

Answer

Further Investigation

Management

Bv and Pregnancy