Case 32
Case 32
Case 32
Content policy
LEARNED
Examinee instructions
Opening scenario
Eva Woods, a 17-year-old female, comes to the physician's office because of a genital lesion.
Vital signs
Temperature: 97.7°F (36.5°C)
Blood pressure: 115/80 mm Hg
Heart rate: 68/min
Respirations: 16/min
Examinee tasks
Take a focused history.
The patient's parents gave consent to perform a relevant physical examination (do not
perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
Explain the preliminary differential diagnoses and initial workup plan to the patient.
Write the patient notes after leaving the room.
NOTES
FEEDBACK
Patient encounter
Patient instructions
You are not aware of the meanings of medical terms (e.g., HPV vaccine) and ask for
clarification if the examinee uses them.
Use the checklists below for history, physical examination, and communication and
interpersonal skills.
Challenge: Ask “Will you tell my parents about this? I do not want them to find out!”
NOTES
FEEDBACK
Focused history
Hovering over the speech bubbles in the lists below will reveal extra information about the
adjacent term. However, clicking on links will cause you to navigate away from the current case,
at which point your progress (i.e., your check marks) will be lost. If you do want more
information on a subject, either open the link in a new tab or wait until you and your partner have
finished the case and reviewed the check marks. Following the link to the patient note form will
not interrupt your progress.
Chief complaint
There is something on the skin in my genital area.
Painful lesion
o No.
Onset
It started 5 days ago.
Constant/intermittent
It is there all the time.
Precipitating events
I cannot think of anything.
Progression
No.
Previous episodes
None.
Alleviating factors
None.
Aggravating factors
None.
Associated symptoms
It has also felt weird when I pee for the past 5 days.
Frequency
o Every time I have to pee.
Recent travel
No, I have not been anywhere recently.
Fever/chills
No.
Rash/skin changes
No.
Bowel problems
No.
Appetite
Normal.
Weight changes
No.
Recent infections
I had two urinary tract infections in the past year, when peeing was pretty painful.
But this time it feels different.
Swelling in groin
No.
Pain in groin
No.
Allergies
I am allergic to latex. I had to wear latex gloves in our biology lab and I got a
horrible rash.
Medications
I take a birth control pill.
Hospitalizations
Only for the removal of my appendix.
Ill contacts
No.
Family history
My father has hypertension and diabetes.
Work
I work as a waitress.
Home
I live by myself in an apartment.
Alcohol
Maybe a beer every other day.
Recreational drugs
Never.
Tobacco
No I do not smoke.
Sexually active
Yes.
With whom
I had multiple partners.
Men or women
Only men.
Protection
I am on the birth control pill. I cannot use condoms because of my latex allergy.
Menarche
I had my first menstrual period when I was 13.
Duration of period
About 4 days.
Period regular
Yes.
Vaginal discharge
Sometimes I have a little bit of discharge. I had more than usual the past 4 days.
Vaginal itching
Yes, my whole genital area has been itchy for the past couple of days.
Vaginal dryness
No.
Pregnancies
No, thank god. I make sure to take my birth control pills every day.
Abortions/miscarriages
No.
Washed hands
Skin examination
Make sure to use respectful draping when examining the inguinal area. A full abdominal
examination should also be performed to assess for signs of pelvic inflammatory disease.
NOTES
FEEDBACK
Examinee demonstrated the ability to support the patient's emotions (i.e., offered
words of support, asked for clarification).
Examinee used non-medical terms and provided reasons for planned steps in
management.
Examinee evaluated the patient's agreement with the next diagnostic steps.
o Examinee asked for consent to perform HIV test.
If a minor is seeking medical care that is related to sex (contraception, pregnancy care, or STIs)
or addiction, parental consent is not required and the information has to be kept confidential.
However, the minor should be encouraged to discuss their issues with their parents. See
also informed consent in minors.
NOTES
FEEDBACK
Patient note
To access the sample patient note, you must first submit your own. Please enter your patient note
in this form: access the patient note here.
For reference, see our list of common abbreviations for the patient note, which is similar to the
list that will be posted at every station during your CS exam: access the abbreviation list here.
NOTES
FEEDBACK
Further discussion
Patient note
Differential diagnoses
1. Human papillomavirus (HPV) infection: HPV infection is the most common STI in
the United States. Human papillomavirus, particularly types 6 and 11,
cause condylomata acuminata , painless lesions on the vulvar, cervix, urethra (rare),
and/or anal region that can also lead to pruritus and tenderness. The condition can be
prevented by using condoms and completing the 2- or 3-shot series of the HPV
vaccination. However, the condition is not typically associated
with dysuria and vaginal discharge, making a coinfection likely in this case.
2. Syphilis: A chancre is caused by infection with Treponema pallidum, a bacteria that is
transmitted through unprotected sexual intercourse. The condition manifests as a single
red, round, and raised painless ulcer with an elevated edge on the vulva or cervix.
However, the condition is often associated with inguinal lymphadenopathy,
and vaginal discharge and pruritus are not typical features. An HPV infection is more
likely to explain this patient's genital lesion.
3. Chlamydia trachomatis infection: Several serotypes of Chlamydia cause chlamydial
genitourinary infections, one of the most common STIs. It can also manifest
as urethritis and vaginal infection that present with (muco)purulent vaginal
discharge and dysuria, as seen in this patient. Specific serotypes of Chlamydia can
also cause lymphogranuloma venereum, a painless genital lesion that manifests as a
transient small papule or ulcer on the posterior vaginal wall, cervix,
and/or vulva. Lymphogranuloma venereum is seen primarily in tropical and
subtropical countries, although the incidence is increasing among men who have sex
with men (MSM) in the US. While it is likely that this patient has a chlamydial
genitourinary infection, her genital lesion is unlikely to be caused by Chlamydia.
Always consider coinfection with multiple sexual transmitted infections, which can lead to
various constellations of symptoms. It is also possible that patients may also have an
asymptomatic coinfection that can only be diagnosed with appropriate testing.
Diagnostic studies
Pelvicexamination: to inspect the genital lesion and vaginal discharge and examine
for signs of pelvic inflammatory disease.
Rectalexamination: to assess for lesions in the rectal area (e.g., often the cases in HPV
infection).
HIV test: should be performed in all high-risk patients; consent must be obtained before
the test is performed.
Rapid plasma reagin test: to test for syphilis.
Darkfield microscopy: definitive tests for detecting primary and secondary
syphilis when a specimen can be obtained (e.g., exudative chancre, condyloma).
Nucleicacid amplification tests for chlamydia and gonorrhea: to test for Chlamydia
trachomatis and Neisseria gonorrhoeae infection.
Urine dipstick, urinalysis: to assess for a UTI.
Wet mount preparation with KOH test: to assess for different forms
of vulvovaginitis (e.g., vulvovaginal candidiasis ).