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.
A 22-year-old woman presents with the chief complaint of a four-day history of mild dysuria, described as, “It burns a bit when I urinate.” She denies fever, GI upset, urinary urgency, and frequency. About one month ago, she entered into a relationship with a male partner who is currently without symptoms. Clinical assessment reveals a friable cervix covered by a thick yellow discharge. Suprapubic, CVA, and cervical motion tenderness are absent. Urinalysis is positive for leukocytes and negative for nitrites, and microscopic examination of vaginal discharge reveals a large number of white blood cells. She's in no acute distress. This condition is most consistent with:
A. Pelvic inflammatory disease.
B. Lower urinary tract infection.
C. Genital herpes.
D. Chlamydia trachomatis cervicitis.
The correct answer is D. Chlamydia trachomatis cervicitis.
Where should you start? First, assess what kind of a question this is. Given that we're being told that she complained and then being asked how to interpret the results, this is a diagnosis question. Now, remember, all diagnoses when we start off are simply working diagnoses. But we have to start somewhere.
Analyzing the content of the chief complaint is a critical portion of looking at the HPI or the history of present illness. And this is one of the first parts of the differential diagnosis process. And remember, differential diagnosis reveals [refers] to the methods by which we choose the possible causes of a patient's clinical findings before making the final diagnosis.
There's a good deal of information in this question to unpack, to be honest with you. Now, let's take a few minutes to pull this apart. Chlamydial infection caused by the organism of C. trachomatis is the most commonly reported STI, most often noted in sexually active adolescents and adults under the age of 25 years. This organism in female birth gender assignment can cause cervicitis and urethral irritation, often resulting with mild dysuria, which she reports. And that's going to be found in about 50% of all females with C. trachomatis infection. At the same time, keep in mind, regardless of birth gender assignment, many with this infection will be without symptoms. Additional signs and symptoms can include a friable cervix, where touching the surface yields brisk bleeding of very short duration, as well as mucopurulent vaginal discharge. And oftentimes that adherent cervical discharge that's mentioned here. Sometimes dyspareunia and post-coital bleeding are also reported. Microscopic examination of cervical or vaginal discharge and C. trachomatis typically reveals a large number of WBCs, not a surprising finding given the WBCs are often mobilized to the site of bacterial infection. And what's infected here? The cervix and the lower reproductive tract.
The patient has a risk factor for new-onset STI presentation in that she has a new partner. Additional risks can include a sex partner who also has a new partner.
With this information and that in mind, let’s break down the question and the potential answers.
A 22-year-old woman presents with the chief complaint of a four-day history of mild dysuria, described as, “It burns a bit when I urinate.” She denies fever, GI upset, urinary urgency, or frequency. About one month ago, she entered into a relationship with a male partner who is currently without symptoms. Clinical assessment reveals a friable cervix covered by a thick yellow discharge. Suprapubic, CVA, which is cost-verterbral angle tenderness, and cervical motion tenderness are absent. UA is positive for leukocytes and negative for nitrites, and microscopic examination of vaginal discharge reveals a large number of WBCs. She's in no acute distress. This presentation is most consistent with:
Pelvic inflammatory disease. This is incorrect. Pelvic inflammatory disease, often abbreviated PID, is an upper reproductive tract infection consisting of endometritis, salpingitis, and oophoritis. In other words, the uterus, the lining of the uterus, the fallopian tubes and the ovaries, and oftentimes even their adjacent structures are involved. While C. trachomatis can certainly cause PID, with Neisseria gonorrhea being the second most likely causative organism of PID, this patient has no fever, no abdominal pain, no cervical motion tenderness. These are all hallmarks of pelvic inflammatory disease. And I'll throw in one more thing. A lot of times PID is mixed organisms; there are a number of different organisms involved. You know, the reality is people present to you with PID are pretty sick. This woman sounds like she's not in particular great distress.
B. Lower urinary tract infection. While she does have dysuria, she lacks urinary frequency and urgency, which are typically reported in UTI. So, what do we make of the WBCs in her urine? A clinical finding that is noted, of course, in UTI. When a person has an STI, often WBCs will be noted in the UA as neutrophils are the body's most helpful response to bacterial infection.
The origin of these WBCs could be the urethritis because she is saying that she has dysuria and C. trachomatis just is quite effective at infecting the urethra as well as the reproductive tract. So, that could be the origin of the WBCs, or it could be WBCs from the cervix or the vagina that end up in the urine being washed off the peri-urethral/perineal area during urination. Obviously, this is not a correct answer.
C. Genital herpes. Well, the lesions of genital herpes can occur around the urethra causing dysuria and pyuria and notation of WBCs in the UA. At the same time, there's no report of the classic vesicular lesions that are noted in genital herpes. The other part is that thick mucopurulent discharge adhering to the cervix is not something you typically would find in genital herpes.
Correct answer of course then is D: C. trachomatis cervicitis. This is the right answer. Her clinical presentation has some of the classic findings of C. trachomatis infection in females, including mild dysuria and cervicitis. The friable cervix is often covered with that thick adherent discharge and WBCs are noted under vaginal microscopy. These are very supportive findings of this presumptive diagnosis.
Of course, this is our working diagnosis and comes under the category, one more time: Common diseases occur commonly. And confirmatory laboratory testing for C. trachomatis should be obtained in this situation.
Key takeaway: At its core, the differential diagnosis process involves acts of selection, where the clinician considers a patient's illness and chooses which disorders are most likely, in part due to the patient presentation and select risk factors.
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