Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert, Dr. Margaret Fitzgerald, shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
Which of the following is most likely to be reported as part of the HPI, history of present illness, in a woman presenting with bacterial vaginosis?
Would it be:
A. A 19-year-old woman with a three-day history of vaginal and perineal itch, white clumping vaginal discharge that has a slight odor that she describes as “musty.”
B. A 24-year-old woman with a one-week history of mild perineal irritation, thin gray-green vaginal discharge with a strong “fishy” odor.
C. A 68-year-old woman with a chief complaint of vaginal irritation, discomfort on vaginal sexual activity, and denies unusual vaginal discharge or odor.
Or
D. A 28-year-old woman with a ten-day history of copious purulent yellow vaginal discharge without unusual odor, but with perineal irritation and mild dysuria.
First, where do you start?
Let's figure out what kind of a question this is. Given we're being told the presenting chief complaint and the presenting diagnosis, i.e. that she has bacterial vaginosis, this is, of course, a diagnosis question.
What do we want to do here? We want to analyze the content of the presenting chief complaint because this is a critical part of the history of present illness, and is one of the first parts of the differential diagnosis process. Differential diagnosis refers to the methods by which we consider the possible causes of a patient's clinical findings before making the final diagnosis.
Let's take a look at some background information. The differential diagnosis of vulvovaginitis is broad, and as it is with all diagnoses, dependent on patient characteristics, risk factors, and presenting signs and symptoms. Well, we're not given a lot of information about each woman. And in clinical practice, we, of course, would obtain more information. This highly focused data type is common on boards. In addition, this question is asking about which one would be most consistent with BV, and we have to keep in mind diagnoses are always fluid, if you will, that once we gather more information, sometimes we could say, Oh no, no, no. I was thinking this was going to be BV it ended up being something else. Indeed, the final diagnosis would correlate with additional HPI, physical exam, and laboratory testing, and which usually includes analysis of vaginal discharge via in-office vaginal microscopy, and quite often sending samples out to the lab.
Let's focus in on the BV diagnosis. This condition occurs when there's a disruption in the normal vaginal flora, allowing for overgrowth of anaerobes, including Gardnerella species and Mycoplasma hominis. In fact, when I first got out of NP school, we called this Gardnerella vaginitis. And then it was recognition that it wasn’t Gardnerella alone, that there are other organisms involved. BV is not considered to be an STI and can be triggered by a number of different factors, including recent antimicrobial use, douching, tub bathing, especially with irritating bubble baths or the like, the use of over-the-counter vaginal hygiene products. And I'm not referring to things like an antifungal or the like, but hygienic products that are promoted to minimize vaginal odor, and the presence of other sexually transmitted infections appears to increase the risk for BV. And the way I usually will describe it to a person I'm seeing with BV is, this is your bacteria, but it's just growing more than it should, and that's what causes it. I will tell you anecdotally, and I really can't find this backed up well in the literature, I have seen women when they change their menstrual product, then respond with BV. Like if they were primarily using pads, they're now using tampons. Or they go from one brand of tampon to another. And I've also seen it among women when they've been super stressed about something, they'll message me, give me a call, and go, It's back again, it's the BV. And then what we can do is take it, take it from there and decide whether she needs to come in or not. One of the most common BV complaints is new onset thin gray to green vaginal discharge with a characteristic odor, particularly after semen exposure, because this triggers an amine release and it results in the fishy smell. But what women will often describe is they feel as if there is an unusual odor even at baseline without semen exposure. Vulvar irritation is often but not consistently reported. And in real-life clinical encounters additional information would be gathered. But let's focus on what the purpose of this question is. Take a look at the choices that are presented.
Which of the following is most likely to be reported as part of the HPI in a woman presenting with bacterial vaginosis?
Would it be:
A. A 19-year-old woman with a three-day history of vaginal and perineal itch and irritation, white clumping vaginal discharge that has a slight odor “musty” odor.
This is incorrect, but this is a classic presentation Candida vulvovaginitis. The key points here are itch is nearly universal with this condition, and that musty or yeasty odor from the Candida species.
Perineal irritation with Candida is quite common and it can be really severe. The report of the white clumping vaginal discharge is the classic presentation of Candida vulvovaginitis. And remember, you're most likely going to be tested on classic presentation of disease.
Now, option B. A 24-year-old woman with a one-week history of mild perineal irritation, thin gray-green, vaginal discharge with a strong fishy odor. This is, of course, our correct answer. The key points here, the color and the consistency of the vaginal discharge, as well as the fishy odor. Perineal irritation with BV, if it's present at all, tends to be mild. On occasion, vaginal or perineal itch is also reported, but not as consistently as we noted with Candida.
But let's of course take a look at the other options.
Option C. A 68-year-old woman with the chief complaint of vaginal irritation, discomfort on vaginal sexual activity, and denies unusual vaginal discharge or odor. Of course, this is incorrect because we've already figured out option B is correct. But what we need to do is, as part of our differential, say, all right, what's special about this situation and this is most consistent with genital urinary syndrome of menopause, abbreviated GSM, formally known as atrophic vaginitis. The key points to the clinical presentation here include the patient's age. So she's 68. She's likely more than 17 years into menopause. And GSM’s etiology is estrogen deficiency. The patient often reports persistent mild dysuria in the absence of UTI and discomfort on vaginal sexual activity, it is all due to estrogen deficiency at the tissue level. Whereas the other vulvovaginitis forms discussed in this question are found predominantly, though not exclusively, in women of reproductive age. This one is specific to women who are in menopause.
Option D. A 28-year-old with a ten-day history of copious purulent yellow vaginal discharge without unusual odor, but with perineal irritation, and mild dysuria. This presentation is more consistent with bacterial vulvovaginitis, perhaps associated with an STI such as chlamydia or gynecological infection. With either chlamydia or GC infection, copious purulent vaginal discharge and mild dysuria are often reported.
And the dysuria is due to the urethritis that often occurs with this condition regardless of birth gender assignment so males, females birth gender assignment urethritis is common with GC and chlamydia.
I do have to say, however, that many people with gonococcal or chlamydia infection are in fact asymptomatic. This option D would be an example of a woman who does have signs and symptoms
suggestive of this.
Key takeaway: At its core, the differential diagnosis involves acts of selection where the clinician considers a patient's illness and chooses which disorder are most likely in part due to patient presentation and select risk factors.
Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast. And for more NP resources, visit FHEA.com.