Jane Wheels is a 24-year-old single female who presents to her nurse practitioner reporting lower abdominal pain, cramping, slight fever, and dysuria of 4 days duration.
History
24-year-old G1P0AB1, LMP 2 weeks ago (regular without dysmenorrhea)
She uses oral contraceptives (for 2 years).
She reports a gradual onset of symptoms of lower bilateral abdominal discomfort, dysuria (no gross hematuria), vaginal discharge with some abdominal cramping, and a slight low-grade fever in the evenings for 4 days. Discomfort has gradually worsened
Denies GI disturbances or constipation. Took Tylenol for fever x 3.
Jane states that she is sexually active and in a monogomous relationship for the past 6 months. Her boyfriend does not use condoms. Reports that they engage in sexual intercourse approximately 2 times per week, vaginal and oral sex, no anal sex. She has had 3 previous sexual relationships in the past, without the use of condoms.
Cooperative and good historian. Non-smoker, exercises regularly, no appetite changes, no travel outside the U.S., and no history of STIs. Reports occasional yeast infections.
Results of office diagnostics:
Urine pregnancy test: negative
Urine dipstick for nitrates: negative
Vaginal saline wet mount: vaginal pH was 4.5. Microscopy showed WBCs >10 per HPF, no clue cells, no trichomonads and the KOH wet mount was negative for budding yeast and hyphae.
What other components of the physical exam should be completed?
What is the differential and most likely diagnosis? Support your answer with information from the case study.
Discuss a treatment plan.
What is an appropriate treatment plan, including CDC-recommended therapeutic regimen for Ms. Wheels?
scholarly written, APA formatted, within 5 years, and referenced. A minimum of 2 references are required.
