Running head: A CASE NARRATIVE OF TRICHOMONIASIS

A Case Narrative of Trichomoniasis

Salena Barnes
Georgia College and State University
A Case Narrative of Trichomoniasis
Patient Name: A.M.
Address: 123 ABC Street Macon, Ga 31204
Date of Service: 08/31/15
Referral Source: Walk-In
Data Source: Patient
Last visit: 06/12/2015 Dr. Patho for PAP smear
Chief Complaint: A.M. is a 25 y/o Caucasian female presenting with complaints of yellowish
vaginal discharge with a bad odor for about a week.
History of Present Illness
The patient is a 25 y/o Caucasian female with no significant medical history other than
treatment for Chlamydia in 2010. She presents today with complaints of a yellowish vaginal
discharge with odor, which she has been experiencing for approximately a week. A.M. is
currently in a monogamous relationship with her husband of two years and receives Depo
Provera injections every three months. She denies fever, abdominal/pelvic pain, burning with
urination, vulvovaginal itching, and skin lesions. Her last PAP smear (done this year) was
normal.
Current Medications
1. Centrum Multivitamin OTC one tablet by mouth daily.
Allergies
1. N.K.D.A.
Past Medical History
1. Chlamydia 2010
2. Usual childhood illnesses.
3. No history of rheumatic fever or prior fractures.
4. Denies having transfusions.
Past Surgical History
1. Appendectomy in 2000.
2. Denies complications with anesthesia.
3. No family history of adverse reaction to anesthesia.
4. Will accept blood transfusions if needed.
Hospitalizations
1. Appendectomy in 2000.
Vaccinations
1. Current on all childhood vaccinations, including Gardasil, Hepatitis A, and B.
2. Tetanus toxoid booster vaccination received in 2014.
3. Denies recent flu/pneumonia vaccination.
Social History
Patient lives in Macon and is a full-time administrative assistant. Currently, resides in a
two-bedroom apartment with her husband. She attends a Baptist church frequently. The patient

A CASE NARRATIVE OF TRICHOMONIASIS

denies tobacco, alcohol, and illicit drug use. No recent travel or sick contacts. Her husband was
laid off from work, placing additional financial stress on their marriage. She believes he is
having an affair. The patient deals with stress by reading, dancing, and listening to music.
Sexual History
Partners: Her first sexual encounter was at 16 years old. She had two encounters prior to
getting married to her husband of two years. She identifies herself as heterosexual and all
her partners have been male. Her last sexual encounter was a week ago with her husband,
which she stated, I believe he is having an affair. States that to her knowledge, her
husband has not seen a doctor in the last 3 years and has not been screened for STDs.
Prevention of pregnancy: She started receiving the Depo Provera injection a year and half
ago, which she is scheduled to receive next month.
Protection from sexual transmitted diseases (STDs): She does not use protection with her
husband and has not used any protection since they were married. However, she stated
that if she has an STD she will use protection from this day forward, regardless of if she
is married or not.
Practices: She reported that she engages only in vaginal intercourse.
Past history of STDs: She was treated for Chlamydia in 2010 (which she contracted from
a former boyfriend), and denies any other history of sexually transmitted diseases. Her
screening this year was negative for all STDs and HIV.
Family History
Unremarkable
24 Hour Diet Recall
Reported diet well balanced
Review of Symptoms
General: Denies fever, chills, malaise, weight gain/loss, and night sweats.
Skin: Denies rash, itching, ecchymosis, and open wounds.
G.I.: Denies pain, nausea, emesis, constipation, incontinence, diarrhea, heartburn,
hematochezia, and melena. Denies any changes in stool pattern, consistency or color.
G.U.: Denies dysuria, nocturia, incontinence, hematuria, urinary frequency, retention and
urgency.
Genitalia/Rectum: + yellowish vaginal discharge with foul odor, denies masses, lesions, rash,
and pain.
Psych: Denies history of depression, +anxiety due to possible STD, denies hallucinations,
delusions, insomnia, suicidal ideations, and suicide attempts. Denies spousal physical or verbal
abuse.
Physical Examination
Vital signs: Temp. 98.2 F, B/P 124/62, HR 77, RR 16, O2 Sat 99% (130 lbs., 68 inches).
Her physical exam was unremarkable except for pelvic exam.
Genitalia/rectum: +Yellow malodorous vaginal discharge with mild edema and erythema
present; No bleeding, adnexal, or cervical motion tenderness; + mild inguinal lymphadenopathy

A CASE NARRATIVE OF TRICHOMONIASIS

Diagnosis with differential

Trichomoniasis
Trichomoniasis affected 2.3 million women in the United States between the ages of 14
to 49 based on those who participated in a National Health and Examination Survey (NHANES)
(Center for Disease Control and Prevention, 2015b). The disease is more common in women
than men and more prevalent in older women versus young women. Trichomoniasis is caused by
a parasite and spread through sexual contact, thus causing an inflammatory process involving the
vagina, cervix, and vulva of a woman and the lower genitourinary tract of a male. A microscopic
organism known as Trichomonas vaginalis causes the condition. Signs of infection may include
postcoital spotting, pruritus, yellow or greenish, frothy, malodorous fishy discharge, as well as
dysuria, dyspareunia, dysmenorrhea, erythema, edema, and irritation of the vulva (The American
College of Obstetricians and Gynecologists, 2011). However, as many as 85% of the women
reported no symptoms. Men are generally asymptomatic and symptoms may include dysuria,
clear penile discharge and itching. The disease is more prevalent among African Americans
(13%), followed by Hispanics (1.8%) and next Caucasians (1.3%). The occurrence of the disease
rises with age and the number of sexual partners. Trichomonads and white blood cells (WBCs)
can be visualized on the wet mount, and the vaginal pH is greater than 4.5. Furthermore, there is
an increased risk for HIV associated with Trichomoniasis (Center for Disease Control and
Prevention, 2015a, 2015b).
Bacterial Vaginosis
Bacterial Vaginosis (BV) is an overgrowth of naturally occurring bacteria in the vagina
(The American College of Obstetricians and Gynecologists, 2011). BV affects approximately
21.2 million women between the ages of 14-49, according to NHANES (Center for Disease
Control and Prevention, 2010). Eighty-four percent of the women reported having no symptoms
and it remains unclear what role sex plays in obtaining this condition. Women who have not had
vaginal, oral, or anal sex can still be affected by BV (18.8%), as can pregnant women (25%), and
women who have ever been pregnant (31.7%). The prevalence among African-American women
is 51%, followed by Hispanics 32% and Caucasians 23%. Characteristics of the disease include
milky white to grayish discharge, vaginal pH greater than 4.5, vaginal itching, and a positive
whiff test (Center for Disease Control and Prevention, 2010)
Vulvovaginal Candidiasis
Vulvovaginal Candidiasis is caused by a yeast organism of the Candida species, in which
C. albicans is the causative organism 85-90% of the time (The American College of Obstetricians
and Gynecologists, 2011). Approximately 75% of all women will have one episode of this
infection during their reproductive years and predisposing factors include factors such as
pregnancy, diabetes, immunosuppression, antibiotic use, and steroid use (Center for Disease
Control and Prevention, 2014b). Symptoms include a one or a combination of the following:
pruritus, erythema, dysuria, irritation of the vulva, edema, discomfort upon penetration and a
thick, curdy discharge. Upon pelvic examination, discharge adherent to the vaginal walls may be
found. The wet mount of the vaginal secretions with utilization of potassium hydroxide (KOH)
will reveal pseudohyphae and budding yeast. Furthermore, the vaginal pH is usually <4.5 with a
negative whiff test (Center for Disease Control and Prevention, 2014b).

A CASE NARRATIVE OF TRICHOMONIASIS

Chlamydia trachomatis
Chlamydia is one of the most common STDs in the United States with a high prevalence
among individuals aged 15-24 years old, with 1,401,906 cases reported in 2013, which is more
common in non-Hispanic blacks (Center for Disease Control and Prevention, 2014a). The
infection is caused by Chlamydia trachomatis and is the cause of 50% of the pelvic infections
and can lead to pelvic inflammatory disease, infertility, and premature labor (Center for Disease
Control and Prevention, 2014a; The American College of Obstetricians and Gynecologists,
2013). Furthermore, the infection can be transmitted vertically to neonates causing pneumonia or
a conjunctival infection, if the woman is not treated. A male or female can be asymptomatic or a
woman may experience symptoms such as spotting, dysuria, vaginal discharge and abdominal
pain. Physical findings in females could include a mucopurulent discharge, as well as erythema,
with an edematous, tender easily to bleed cervix. Males may present with mucopurulent penile
discharge. Moreover, presence of the organism can be detected using a urine specimen for the
nucleic acid amplification test (NAAT) or by cultures (The American College of Obstetricians
and Gynecologists, 2013).
Gonorrhea
Gonorrhea is the second most common STD in the United States and is caused by the
Niesseria gonorrhea, which can lead to PID thus precipitating tubal infertility, ectopic
pregnancies, and chronic pelvic pain (Center for Disease Control and Prevention, 2014c; The
American College of Obstetricians and Gynecologists, 2013). Furthermore, as with all sexual
transmitted infections studies have shown that STDs facilitate the transmission of the HIV
infection. In the United States, there is a high prevalence among individuals aged 15-24 years
old, with 333,004 cases reported in 2013. Gonorrhea can be transmitted to neonates during birth
and the incubation period is approximately three to five days. Risk factors for all STDs include
multiple sex partners, inconsistent condom use, prostitution and illicit drug use. Individuals may
be asymptomatic or symptomatic at various sites of the body such as anal, vaginal, pharynx and
penis. Males and females may experience a purulent discharge. Moreover, presence of the
organism can be detected using a urine specimen for the nucleic acid amplification test (NAAT)
or by cultures. A coinfection usually exists between C. trachomatis and Gonorrhea, thus patients
are treated for both (Center for Disease Control and Prevention, 2014c; The American College of
Obstetricians and Gynecologists, 2013).
Planned Interventions
Labs

OraQuick HIV test negative

Blood specimen collected for VDRL
Urine specimen collected for NAAT (Gonorrhea and Chlamydia)
Wet mount collected: Trichomonads present, WBCs>10, Vaginal pH>4.5; Negative for
BV, Negative whiff test, and Negative Candida vulvovaginitis
Please see the link included for additional information about sensitivity or specificity of
test for diagnosing: http://www.cdc.gov/std/tg2015/trichomoniasis.htm

A CASE NARRATIVE OF TRICHOMONIASIS

Diagnosis
The diagnosis of Trichomoniasis was determined due to the wet mount results, as well as
presentation of signs and symptoms. Will follow-up in two weeks with laboratory results unless
indicated sooner. However, if signs or symptoms persist of worsen the patient is to contact office
immediately.
Pharmacological Plan
Flagyl (Metronidazole) 500 mg 1 tablet PO BID for seven days OR
Flagly (Metronidazole) 2 gram single oral dose
Education
Patient received educational pamphlets on Trichomoniasis and prevention of STDs. She
was informed that her husband would need to be treated to prevent reinfection and her results
from other testing should be back within two weeks. She was advised to avoid any sexual contact
until treatment was complete, her husband received treatment, and neither were experiencing
further signs/symptoms. Patient instructed on appropriate use of barriers methods to prevent
STDs vaginally, orally, and anally. Educational materials and demonstration provided, as well as
an opportunity for patient to return demonstrate proper use of prophylactics. The patient was
advised to repeat the HIV test in six months due to the varying window period in which you can
test negative even though she may be infected. She was informed to avoid alcohol while taking
Flagyl and 72 hours following last dose due to disulfiram-like reaction, which is severe nausea
and vomiting. The patient verbalized understanding and has no further questions at this time.
Instructed to contact office if she has any further questions.

A CASE NARRATIVE OF TRICHOMONIASIS

References
Center for Disease Control and Prevention. (2010). Bacterial Vaginosis (BV) Statistics.
Retrieved from http://www.cdc.gov/std/bv/stats.htm
Center for Disease Control and Prevention. (2014a). Chlamydia. Retrieved from
http://www.cdc.gov/fungal/diseases/Candidiasis/genital/
Center for Disease Control and Prevention. (2014b). Genital / vulvovaginal candidiasis (VVC).
Retrieved from http://www.cdc.gov/fungal/diseases/Candidiasis/genital/
Center for Disease Control and Prevention. (2014c). Gonorrhea. Retrieved from
http://www.cdc.gov/std/stats13/gonorrhea.htm
Center for Disease Control and Prevention. (2015a). Trichomoniasis. Retrieved from
http://www.cdc.gov/std/tg2015/trichomoniasis.htm
Center for Disease Control and Prevention. (2015b). Trichomoniasis Statistics. Retrieved from
http://www.cdc.gov/std/trichomonas/stats.htm
The American College of Obstetricians and Gynecologists. (2011). Vaginitis. Retrieved from
http://www.acog.org/Patients/FAQs/Vaginitis#why
The American College of Obstetricians and Gynecologists. (2013). Gonorrhea, Chlamydia, and
Syphilis. Retrieved from http://www.acog.org/Patients/FAQs/Gonorrhea-Chlamydiaand-Syphilis