Nora’s first sexual encounter was at age 16. She has had 4 encounters in the past 2 years with 2 different partners, with 2 encounters in the last 2 months.
Prevention of pregnancy: Nora was prescribed a triphasic oral contraceptive at age 16 but says “I stopped taking it after a few months and haven’t been on any since.” Her partners “use condoms once in a while.”
Prevention of STIs: Limited to inconsistent condom use.
Practices: Nora describes her encounters as limited to vaginal intercourse and “oral sex once in a while.” She denies anal sex.
Past history of STIs is negative.
OBJECTIVE
General: Anxious 18‐year‐old female in no acute distress. Well groomed with good hygiene. Cooperative.
Vital signs: Height: 5 ft 4 inches; weight: 112 lbs; BMI: 21.2; temperature: 97.8°F; B/P: 118/72; HR: 98.
Respiratory: Normal respiratory effort, CTA bilaterally.
Cardiac: Regular rate, rhythm. No murmurs, gallops.
Breasts: Tanner IV.
With Nora’s consent a pelvic exam was done.
Pelvic/Genital exam: No vulvar or vaginal lesions. Mucoid, nonodorous discharge was noted and vaginal and endocervical swabs obtained. Cervix appeared inflamed but was nonfriable and there was no cervical motion tenderness (CMT). Discomfort but no tenderness on bimanual examination.
CRITICAL THINKING
1 Which diagnostic studies should be considered to assist with or confirm the diagnosis?___Urine HCG___Nucleic acid amplification test (NAAT) for chlamydia___NAAT for gonorrhea___Wet mount (saline, KOH prep of vaginal secretions) to rule out coexisting infection___HIV‐1 antibody testing___Venereal Disease Research Laboratory (VDRL)
2 What is the most likely differential diagnosis and why?___Chlamydia (C. trachomatis)___Gonorrhea (N. gonnorhoeae)___Bacterial vaginosis___Trichomonas vaginalis___Pregnancy___HIV
3 What is the plan of treatment?
4 How should this patient be counseled regarding the prevention of STIs?
5 Is this patient at risk for HIV?
6 Should this patient be retested for cure after treatment?
7 Should this patient’s partners be treated?
Case 5.7 Sexual Identity
By Betsy Gaffney, MSN, APRN, FNP‐BC
SUBJECTIVE
Michelle, a 17‐year‐old Caucasian female, presents to a primary care practice where she has been a patient since 5 years of age. She is accompanied by her maternal aunt. Michelle is usually accompanied by her mother. She is up to date with her immunizations including HPV series. Her last visit was 10 months ago for strep pharyngitis. She was very quiet and less interactive at that visit but when asked if anything was bothering her said “just my throat.”
Michelle tells you she is here today because she identifies “more as a boy,” saying “I’ve felt this way for about 2 years but was afraid to tell anybody before. I’m not afraid now and have told my mother and my aunt. I’m tired of lying by not saying anything and want to do things differently. My mom said I should come and talk to you because we like and trust you.” Michelle’s aunt verifies this, saying, “My sister is still a little freaked out about this but wants what is best for Michelle. That’s why she asked me to come with her today.” Michelle’s mom would also like her to have a physical check‐up, since she hasn’t been seen for almost a year. Michelle’s aunt leaves the exam room to allow her privacy.
Past medical/surgical history: Michelle has a positive medical history for strep pharyngitis, which resolved with antibiotics. She has no chronic illnesses, surgery, or hospitalizations.
Menstrual history: She began menarche at age 11 with a regular 28‐day cycle and moderate bleeding. She expresses a desire to “not have my period.”
Family history: Maternal family history is positive for grandmother with COPD, grandfather with hypertension. Mother and 9‐year‐old sister have no health issues. Paternal history is unknown. Father has problems with substance abuse.
Social history: Michelle lives with her mother and younger sister in a rural, farming area. Her father is known but has little contact with the family. Michelle is a sophomore at the public high school. Her mother works full‐time at a local manufacturing plant. Michelle has a close relationship with her mother and maternal aunt. She denies alcohol and tobacco use, does admit to “smoking weed once but I hated it.” She denies depression but admits previous anxiety about her lifestyle choice. She reports her anxiety is “pretty much gone” since she has “come out” to her mother and aunt. She admits being attracted to other girls but denies any sexual experiences. She has recently told a few other students about identifying as a boy, noting “it’s hard to be different in this area.”
Medications: No regular medications.
Allergies: Seasonal (spring) allergies. NKDA.
OBJECTIVE
General: Alert, pleasant adolescent; well groomed with good hygiene. Cooperative with good eye contact.
Vital signs: Height: 63.5 inches; weight: 112 pounds; BMI 19.5 (43rd percentile); B/P: 108/70; HR: 72; RR: 15.
Cardiac: RRR; S1‐S2 normal; no murmur, rub, or gallop.
Respiratory: Normal respiratory effort; lungs clear to auscultation bilaterally.
Abdominal: Soft, nondistended, nontender, with positive bowel sounds x 4 quadrants.
Breasts: Tanner stage IV.
PHQ‐9: Negative.
CRITICAL THINKING
1 What concerns should be addressed at this visit?_____Sexual identity_____Anxiety/Depression_____Desire for amenorrhea
2 What case‐specific questions should be asked addressing Michelle’s desire for amenorrhea?
3 Are any referrals needed?
4 What complications exist related to the rural setting?
5 Are there implications for future medical care?
6 What psychosocial challenges present with “coming out”?
