motion tenderness (CMT). The pH of the vaginal discharge is within normal range (3.8–4.2).
CRITICAL THINKING
1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Pap smear___Cultures for gonorrhea and chlamydia___Urine testing for gonorrhea and chlamydia___Wet mount, including KOH and whiff test___Urinalysis
2 If a wet mount were performed, what findings would be expected for the following diagnoses?Bacterial vaginosisCandidiasisTrichomonas
3 What is the most likely differential diagnosis and why?___Bacterial vaginosis___Candidiasis___Trichomonas___Gonorrhea___Chlamydia___Herpes simplex___Urinary tract infection
4 What is the plan of treatment?
5 What education should be provided to Martha at this visit?
6 Are any referrals needed?
7 Is the family history of diabetes relevant to this case?
8 How can the clinician support the patient regarding her confusion with her sexual preferences?
NOTE: The author would like to thank Leslie Neal‐Boylan, PhD, APRN, CRRN, FAAN, FARN for her contribution to this case in the first edition of this book.
Case 6.6 Redness and Swelling in the Breast
By Karen M. Flaherty, MSN, MEd, APRN‐BC, CBCN
SUBJECTIVE
Jill is a 26‐year‐old female who presents today for evaluation of redness, swelling, and pain in her right breast. Three months ago she underwent bilateral nipple piercings while on vacation in the Caribbean. Both sites had healed well until 4 days ago, when she noted “mild” redness on her right lower breast. This has increased in size and depth of color and she began experiencing swelling and pain in the right breast. Last night she noted a small amount of drainage on the right side of bra and felt mildly feverish.
Past medical history: Jill is an otherwise healthy 26‐year‐old female of Ashkenazi Jewish heritage who had the usual childhood illnesses. Her immunizations are up to date. She’s had no chronic illnesses and has no past surgical history.
Family medical history: Jill’s mother and father (Ashkenazi Jewish) are alive and well. She has 2 brothers, ages 20 and 18, with no significant medical problems. Her paternal grandmother is age 67 and has Type 2 diabetes mellitus; she was treated for left breast cancer at age 43 and tested positive for the BRCA 1 and 2 gene. Jill’s paternal grandfather is age 70 and is alive and well. Her maternal grandmother is age 65 and has high blood pressure; her maternal grandfather is age 67 and alive and well.
Social history: Jill graduated with a degree in art and works as an assistant in an art gallery; she is applying to graduate school. Jill lives in Boston with a female roommate. Her alcohol intake includes 2–3 glasses of wine on the weekend. She has been smoking 3–4 cigarettes per day since age 20. She performs Pilates 2–3 times per week.
Medication: Daily BCP, MVI, Tylenol if needed for headache.
Allergies: Seasonal sllergies (spring), penicillin (rash and hives).
OBJECTIVE
General: Pleasant young woman, who appears mildly unwell, in moderate discomfort; rates pain 4/10 located in R breast.
Vital signs: Temperature: 100.4°F; P: 90; BP: 100/60.
Cardiac: Rate 96 and regular, no murmurs heard on auscultation.
Respiratory: Rate 16 breaths per minute, lungs clear to auscultation in all lobes.
Skin: Face is flushed. Right breast has marked redness and warmth over the lower half, left breast no redness or increase in temperature.
Breast: Right breast is slightly swollen, with erythema extending over the lower half of the right breast, central area of induration within the area of erythema. Mild skin thickening and edema noted. There is a ring piercing through the right nipple, no drainage seen. Right breast has a tender area of induration within the central portion of the erythema. No other discrete or dominant masses found. No observable drainage seen from right breast. Left breast has a ring piercing through the left nipple, no swelling, erythema, or induration, also with piercing through the left nipple. Left breast is smooth to palpation with no discrete or dominant masses noted, no painful areas on palpation.
Lymph: Left axillary nodes nonpalpable, nontender. Right axilla has 2 mobile, nontender, 0.5 cm, oval palpable nodes.
CRITICAL THINKING
1 Which diagnostic tests should be considered?
2 Which differential diagnoses should be considered?
3 What is the most likely differential diagnosis and why?
4 What is the plan of treatment?
5 What is the plan for follow‐up?
6 Would the workup or treatment be different if this patient were a man?
7 Are any referrals needed?
8 What health education is important for this patient?
Case 6.7 Sexual Assault
By Meredith Scannell, PhD, MSN, MPH, CNM, CEN, SANE‐A
SUBJECTIVE
Aiyata is a 22‐year‐old female who presents requesting treatment for sexually transmitted infection. She reports she recently graduated from college and was out celebrating the graduation with some friends last night. She reports going to a bar where she met with a male friend who bought her drinks. She has a vague recollection of the night but awoke today naked in the bed with the male friend. She has a vague memory of having sex with the male friend but does not recall many of the details; she is not sure if a condom was used. She is concerned because she has been having vaginal spotting since the event and some pain and discomfort in the vagina.
Past medical history: Depression, childhood sexual abuse, post‐traumatic stress disorder.
Past surgical history: None.
Menstrual history: LMP 2 weeks ago; she reports a 28‐day cycle and no menstrual irregularities.
Genitourinary: Reports some dysuria that started this morning.
Family history: Aiyata’s mother has a history of alcohol abuse and hypertension. Her father’s history is unknown.
Social history: Aiyata was raised in a single‐parent
