Family Nurse Practitioner: Vaginal Discharge Case Study and Treatment

This assignment presents a comprehensive case study from a Family Nurse Practitioner (FNP) perspective, focusing on a 40-year-old Hispanic female presenting with vaginal discharge and a fishy odor. The report meticulously details the subjective and objective data collection, including the patient's chief complaint, medical history, and vital signs. It delves into differential diagnoses, such as bacterial vaginosis, trichomoniasis, and candidiasis, providing rationales based on the patient's history and potential physical exam findings. The assignment outlines a treatment plan, including pharmacological interventions like metronidazole and clindamycin, while also emphasizing patient and family teaching regarding medication, hygiene, safe sex practices, and the importance of follow-up. Furthermore, it incorporates a critique of a relevant research article and discusses the implications of the patient's ethnicity and cultural background on her care, including the need for pap tests and mammograms. The report underscores the significance of patient education, health promotion, and preventative measures specific to the patient's needs, ensuring a holistic approach to healthcare delivery. The assignment concludes with a detailed analysis of diagnostic tests and their utility in confirming the diagnosis of bacterial vaginosis, and a discussion on the importance of patient education, health promotion, and preventative measures specific to the patient's needs.

Running head: Family nurse practitioner (Vaginal discharge)
Family nurse practitioner (Vaginal discharge)
Name of the Student
Name of the university
Author’s note

Family nurse practitioner (Vaginal discharge)
1. Subjective data
It order to gain a subjective finding of the data. The doctor might ask for pain, as abdominal
may indicate towards urinary tract infection, chlamydia and gonorrjea , or the colour of the
secretion ranging from white, grey, yellow or brown. It is necessary to know about the
consistency of the discharge, whether it is thin, thick of frothy. Bacterial vagnosis can give
greyish white coloured secretion. It is also necessary to ask the patient about the presence of
fever and malaise. The woman should be enquired about the any itching or burning sensation
at the time of sexual intercourse. Some of the other subjective information would include
past history of any infection or about the sexual partner, starting from the sex of the partner
(Mlisana et al., 2016). There are several sexually transmitted diseases that can be spread by
unprotected sex from the partner. It is necessary to know about the history of douching and
the home remedies or any leftover treatment from the past infections. History taking should
also contain information about the recent medications, as recent medications can alter the
physical as well as the laboratory examination.
2. Objective component
Eliciting the cause of the vaginal discharge needs a proper gynaecologic history with special
attention given to the following details like the age of the woman, the last menstrual period ,
the regularity , the timings of the period cycles needs to be confirmed, or if the woman had
been under any birth control pill. It is also necessary to understand the amount and the
duration of the flow. It is necessary to know her hormonal status (Premenopausal in this
case). This is due to the fact that yeast infection occurs after menses, whereas the
trichomonus occurs just after the menses. It is necessary to enquire about the previous files of

Family nurse practitioner (Vaginal discharge)
past treatment and ant allergies against any medicine and the nature of the reaction. It is also
necessary to review other system like abdomino-pelvic, gynaecologic, urinary,
gastrointestinal and breast infection. History of immunization needs to be enquired. Dates
and the results of the screening tests like mammography or pap test or colonoscopy should
always be asked for.
3. Diagnoses
Differential diagnosis
The differential diagnosis of bacterial vaginitis includes infection with Trichomonas
vaginalis and Candida albicans, normal vaginal discharge and aerobic vaginitis. The symptom
of trichomoniasis has similar symptoms to bacterial vaginitis, except the fact, that it is
characterized by a frothy consistency in the vaginal discharge and is a sexually transmitted
disease. Chlamydial infection can be present as vulvovaginitis. Cytolithic vaginitis can be
referred to as a common cause of cyclic vulvo-vaginitis. This is majorly caused due to
overgrowth of the Lactobacilli in the vagina (Anand, Singh & Unisa, 2015). The microscopic
flora of the BV is granular which is different to that of aerobic vaginosis, where the bacteria are
less in numbers. This might also cause an increase in the vaginal acidity. However, the diagnosis
of the bacterial vaginosis will be made by the detection of at least three of the following findings
like a thin and homogenous discharge, pH greater than 4.5, positive amine test and the presence
of the clue cells (Hemalatha et al., 2016). Vaginal gram staining can be done as the conformation
test (Ibrahim et al., 2013).

Family nurse practitioner (Vaginal discharge)
Patient and family teaching
Patient and family education is an important part of any treatment program. Safe sex and
STD counseling can be helpful in decreasing the rate of the reinfection. The patient should be
taught about proper toilet and hygiene techniques (Zaher, Khedr & Elmashad, 2017). Patients
should be reminded about the fact that douching can cause spreading of the cervical and the
vagina secretion (Ibrahim et al., 2018). Douching can also be associated with endometriosis. The
patient needs to be educated about the use of the topical creams for the treatment of the vaginitis
for example candida vaginitis and bacterial vaginitis are necessary. The patient should be
educated about the maintenance of hygiene, such as bathing with the non-irritating and unscented
soaps, patting dry without rubbing, using white toilet paper ad using deodorant free sanitary pads
or tampons. It is necessary to have just a single partners (Zaher, Khedr & Elmashad, 2017).
The patient should be informed clearly about the clinical manifestations that one might
likely face and the importance of reporting of the symptoms. They should be discussed about the
risk factors, the medicines that needs to be taken and the follow up (Ibrahim et al., 2016).
Pharmacological interventions like metronidazole , 500 mg orally twice daily for 7 daysb,
clindamycin (2%) cream and 5 gm intravaginally once or twice daily for long 5 days . all these
three intenventions have shown to reduce the infection rates by 80-90 %. Intravaginal
metronidazole has been found to be showing lesser adverse reactions (Donders, Zodzika &
Rezeberga, 2014). Oral clindamycin for 7 days can be related to higher incidence of diarrhea as
compared to oral metronidazole.
Bacterial vaginosis has been associated with the diet and the nutritional status of women.
It has been found in several studies that there is an association between BV and poor nutritional

Family nurse practitioner (Vaginal discharge)
status including the deficiency of Vitamin E, A, C, D, E and beta carotene. It has also been
related to low intake of minerals like folate, vitamin E and calcium. According to a study by
Thoma, et al., (2011), It has been found that occurrence of bacterial vaginosis has been found to
be higher in women with high fat consumption. However, diets which are high in fats and
energies are considered as food of poor quality (Thoma, et al., 2011). Probiotics can be helpful
for maintaining the acidity level of the vagina. They tends to regulate normal micro flora of the
vagina. They stop good bacteria in the probiotics competes with the pathogens to get adhered to
the vaginal tissue. This patient can be educated to consume the prebiotic compounds that will
help to stabilize the pH level of the vagina. Some of the food that are rich in prebiotics includes
onions and leeks, asparagus and Jerusalem artichoke, whole wheat products, oats and soybeans,
bananas (Pandey, Naik & Vakil, 2015).
Treatment plan
Diagnostic tests
Positive whiff amine test- the vaginal discharge is placed with 10 % potassium hydroxide
solution and a fishy smell is obtained. Thus a positive result is obtained. The fishy smell is due to
the release of the amines like cadaverine, putrescine and trimethylamine (Damke, Fule &
Tankhiwale, 2016).
Vaginal gram stain- This has been regarded as a reliable test for the diagnosis of bacterial
vaginosis and provides a permanent record. The gram staining confirms the presence of the gram
negative bacteria.

Family nurse practitioner (Vaginal discharge)
Presence of clue cells on wet-mount microscopic evaluation-The sensitivity value and the
specificity of this test ranges from 80-100 %. Presence of clue cells confirms bacterial vaginosis.
Clue cells are vaginal squamous epithelial cells coated with anaerobic gram variable
Gardenerella vaginalis.
Medications
Metronidazole destroys the bacterial cells by disrupting their DNA. The gel is applied
inside the vagina at the bed time. Some of the other antibiotics like azithromycin, ofloxacin
should never be used for the treatment. Clindamycin can be inserted in the vagina at bed time.
Antiseptocs have antibacterial action against a large number of aerobic and anaerobic bacteria by
the disruption of the cell membrane. Antiseptics such as benzydamine, deqialiniumchoride and
providone iodine can be provided in gel formulation. Clindamycin inhibits the bacterial protein
synthesis and thus destroying the bacteria. Any relapse of the disease can be treated with a
prolonged course of the vaginal metronidazole.
Analysis of each of the tests
The sensitivity and specificity of amine test for vaginosis is about 97.6% and 85.7%
respectively. The cost of the whiff amine test is less than that of the gram staining. The cost of
the microscopic examination is more than that of the amine test or gram staining (Donders et al.,
2015).
Research Article Critique
Donders, Zodzika and Rezeberga, (2014) has stated the diagnosis of bacterial vaginosis
can be confirmed by the increase of the vaginal pH and the typical microbial flora under

Family nurse practitioner (Vaginal discharge)
microscope. The paper gives a detailed review about the types of antibiotics and the antiseptics.
All the information that has been provided are supported by a large number of references. The
paper has provide much detail about the role of the prebiotics and the prebiotics in normalizing
the microflora.
Web address: https://www.tandfonline.com/doi/abs/10.1517/14656566.2014.881800
Billing
N76. 0 is a billable/specific ICD-10-CM code that can be used for indicating a diagnosis for
reimbursement purposes bacterial vaginosis.

Family nurse practitioner (Vaginal discharge)
References
Anand, E., Singh, J., & Unisa, S. (2015). Menstrual hygiene practices and its association with
reproductive tract infections and abnormal vaginal discharge among women in India.
Sexual & Reproductive Healthcare, 6(4), 249-254.
https://doi.org/10.1016/j.srhc.2015.06.001
Damke, S. S., Fule, R. P., & Tankhiwale, N. S. (2016). Utility of Ph and whiff test for screening
of abnormal vaginal discharge among women of reproductive age in rural area.
International Journal of Current Research and Review, 8(10), 33.
Donders, G. G., Marconi, C., Bellen, G., Donders, F., & Michiels, T. (2015). Effect of short
training on vaginal fluid microscopy (wet mount) learning. Journal of lower genital tract
disease, 19(2), 165-169.
Donders, G. G., Zodzika, J., & Rezeberga, D. (2014). Treatment of bacterial vaginosis: what we
have and what we miss. Expert opinion on pharmacotherapy, 15(5), 645-657.
https://doi.org/10.1517/14656566.2014.881800
Hemalatha, R., Ramalaxmi, B. A., Swetha, E., Balakrishna, N., & Mastromarino, P. (2013).
Evaluation of vaginal pH for detection of bacterial vaginosis. The Indian journal of
medical research, 138(3), 354.
Ibrahim, S. M., Bukar, M., Mohammad, Y., Audu, B. M., & Ibrahim, H. M. (2013). Prevalence
of vaginal candidiasis among pregnant women with abnormal vaginal discharge in

Family nurse practitioner (Vaginal discharge)
Maiduguri. Nigerian Journal of Medicine, 22(2), 138-142.
https://www.ajol.info/index.php/njm/article/view/89816
Mlisana, K., Naicker, N., Werner, L., Roberts, L., Van Loggerenberg, F., Baxter, C., ... &
Ronacher, K. (2012). Symptomatic vaginal discharge is a poor predictor of sexually
transmitted infections and genital tract inflammation in high-risk women in South Africa.
The Journal of infectious diseases, 206(1), 6-14.
Pandey, K. R., Naik, S. R., & Vakil, B. V. (2015). Probiotics, prebiotics and synbiotics-a review.
Journal of food science and technology, 52(12), 7577-7587.
Thoma, M. E., Klebanoff, M. A., Rovner, A. J., Nansel, T. R., Neggers, Y., Andrews, W. W., &
Schwebke, J. R. (2011). Bacterial vaginosis is associated with variation in dietary indices.
The Journal of nutrition, 141(9), 1698–1704. https://doi.org/10.3945/jn.111.140541
Verstraelen, H., & Swidsinski, A. (2013). The biofilm in bacterial vaginosis: implications for
epidemiology, diagnosis and treatment. Current opinion in infectious diseases, 26(1), 86-
89.
Zaher, E. H., Khedr, N. F. H., & Elmashad, H. A. M. (2017). Awareness of Women Regarding
Vaginal Discharge. IOSR J Nurs Heal Sci, 6, 01-12.