Ms. V is a 21 year old who gave birth to her first child 8 weeks ago. She comes in for her postpartum GYN exam with a multitude of questions and problems. First, she asks about birth control options. Next, she mentions that she thinks she has a UTI; she has been treated for the UTI “few times” but it never seems to go away. She also thinks she may have a yeast infection, which she treated with Monistat 7, but it never completely went away. Ms. V also has had a lump in her right breast for almost 2 years; her provider told her “not to worry about it.”
We started with a discussion about birth control. She used to use Depo but wants to try the patch. Then we did the breast exam. She has a 1.5 cm solid, movable, painless mass in her right breast at about 1200. Next, I do the PAP. It is obvious that she has a yeast infection. She has the typical “cottage cheese” discharge but I also smell “something fishy.” We process slides to check for Candida and BV; the slides confirm both.
The plan for Ms. V is:
Referral to the breast clinic – a lump that remains after 2 years and is bothering the patient should be checked out.
UA/C&S – The UTI has not resolved probably due to the persistent BV/Candida.
Miconazole cream x 7 days to treat the Candida.
Metronidazole x 7 days to treat the BV.
Miconazole and metronidazole to be taken concurrently to maximize treatment. My preceptor states that the yeast infection never resolved because the BV was never treated. Both need to be treated at the same time.
Contraceptive patch – Start on the Sunday after the start of next menses.
I thought this was an interesting case because there was a little bit of everything – a breast mass, BV, Candida, a PAP, contraception, and a UTI – all in one 30-minute appointment.
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Hello CPT Masse! I have a few questions for you. When did she resume sexual activity? Did she have a yeast infection in pregnancy? Did she deliver early or was the baby a full term baby? Was the baby low birth weight? I am just trying to figure out if the patient had BV during her pregnancy as it would increase her risk for preterm labor and even a low birth weight baby. I do know how frustrating it can be trying to do all that in a 30 minute patients. On the flip side it is good to know that the clinics in Virginia are not the only ones that run into complications that require more then 30 minute appt slots. Just that one 30 minute slot that now takes 40 minutes can offset your entire day.
ReplyDeleteLorraine-Wow. Great time management-30 minutes. Thank goodness for the appointments that take 10 minutes instead of 20 or 30. I had a postpartum patient that had one complaint-vaginal irritation. As it turned out she had BV and Trichamonas! All floating under the microscope. We used the same antimicrobial but instead of a tablet for metronidazole we prescribed Metrogel. Metrogel is a vaginal route. The patient was not a big fan of taking pills.
ReplyDeleteGreat case - just brings home the point that many things are "connected" and to really provide good care you need to reach across the "pools" of knowledge in your brain!
ReplyDeleteOne comment for you, Susan - trich can migrate around, so vaginal treatment is probably not the BEST strategy - the organism can just avoid it and re-populate when the Metrogel is gone. Trich is one case where you really should treat systemically and not locally.