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2 types of intercourse are at the highest risk for contracting HIV

Case Scenario 1

Table 1
Infection Description Presentation Causes/ Risk Factors Treatment per CDC Addtl info
Candida
BV
Chlamydia
Gonorrhea
Trichomonas
Cervicitis
PID
HIV
Syphilis
Hep B
Hep C
HSV

Table 2
Question Answer
Name 10 Risk Factors for contracting STI’s and HIV

Name 5 safer sex practices

Can HIV be transmitted through sweat, saliva, and tears? (Include rationale)
Name 2 types of intercourse are at the highest risk for contracting HIV
Why are women more susceptible to HIV in a male to female relationship (versus a male contracting it from a female)?

Lisa is a 19-year-old female who presents to the clinic c/o abnormal vaginal discharge for one week after having unprotected vaginal intercourse with a new male partner she has been dating for a couple of weeks. Lisa’s pregnancy test is negative and her LMP was 2 weeks ago. As her health care provider, you will need to perform testing to determine if Lisa has contracted a sexually transmitted infection or other vaginal infection.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

Subjective:
a. What other relevant questions should you ask regarding the HPI?
b. What other medical history questions should you ask?
c. What other social history questions should you ask?
Objective:
a. Explain what POCT will you order and perform, and discuss your rationale for ordering and performing each test.
Assessment/ Diagnosis:
a. What would be an appropriate diagnosis for her? Why?
b. Any other diagnosis or differential diagnosis you would like to add?
Plan:
a. What will you prescribe for this patient? Why? (assume one of your lab test results is positive), Explain what medications and treatments you would recommend
b. Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s), partner notification, and follow-up plan of care.
c. What patient education is important to include for this patient? (Consider when can the patient resume sexual activity)
d. Explain complications that can occur if patient does not comply with treatment regimen.

Full Answer Section

Frothy, yellow-green discharge, itching, burning, "strawberry cervix"	Unprotected sex	Metronidazole, tinidazole	Partner treatment essential
Cervicitis	Inflammation of the cervix	Abnormal discharge, pelvic pain, bleeding between periods	STIs (chlamydia, gonorrhea), allergies	Treat underlying cause (antibiotics for STIs)	Can lead to PID if untreated
Pelvic Inflammatory Disease (PID)	Infection of female reproductive organs	Pelvic pain, fever, abnormal discharge, pain during intercourse	Untreated STIs (chlamydia, gonorrhea)	Ceftriaxone + doxycycline +/- metronidazole	Can cause infertility
HIV	Viral infection	Flu-like symptoms, fatigue, weight loss, opportunistic infections	Unprotected sex, sharing needles, mother-to-child transmission	Antiretroviral therapy (ART)	No cure, but ART controls viral load
Syphilis	Bacterial infection	Sores (chancres), rash, fever, fatigue, neurological symptoms	Unprotected sex	Penicillin G	Can cause serious complications if untreated
Hepatitis B (Hep B)	Viral infection	Fatigue, jaundice, abdominal pain, dark urine	Unprotected sex, sharing needles, mother-to-child transmission	Antiviral medications, vaccination	Can cause liver damage
Hepatitis C (Hep C)	Viral infection	Often asymptomatic, fatigue, abdominal pain, jaundice	Sharing needles, blood transfusions (before 1992), unprotected sex (less common)	Antiviral medications	Can cause liver damage
Herpes Simplex Virus (HSV)	Viral infection	Painful blisters or sores, itching, burning, flu-like symptoms	Skin-to-skin contact (oral, genital)	Antiviral medications (acyclovir, valacyclovir)	No cure, but medication reduces outbreaks

Table 2: STI/HIV Risk Factors and Safer Sex Practices

Question	Answer
10 Risk Factors for STIs and HIV	1. Unprotected sex (vaginal, anal, oral), 2. Multiple sexual partners, 3. History of STIs, 4. Sharing needles, 5. Lack of barrier methods (condoms), 6. Sex with a partner who has an STI, 7. Not being vaccinated (Hep B, HPV), 8. Exchanging sex for drugs or money, 9. Having sex while intoxicated, 10. Lack of knowledge about STIs
5 Safer Sex Practices	1. Consistent condom use, 2. Limiting sexual partners, 3. Regular STI testing, 4. Open communication with partners, 5. Vaccination (Hep B, HPV)
HIV Transmission through Sweat, Saliva, Tears?	No. HIV is transmitted through specific bodily fluids (blood, semen, vaginal fluids, breast milk). Sweat, saliva, and tears do not contain enough HIV to transmit the virus.
2 Highest Risk Intercourse Types for HIV	1. Anal intercourse, 2. Vaginal intercourse
Women More Susceptible to HIV (Male-to-Female)?	Women have a larger mucosal surface area exposed during vaginal intercourse, increasing the risk of transmission. Semen also contains a higher concentration of the virus than vaginal fluids.

SOAP Note: Lisa, 19-Year-Old Female

S (Subjective):
- HPI: Lisa is a 19-year-old female presenting with abnormal vaginal discharge for one week. She reports unprotected vaginal intercourse with a new male partner a couple of weeks ago. She denies fever, chills, abdominal pain, or other symptoms.
  - Additional HPI Questions:
    - Characterize the discharge (color, odor, consistency).
    - Any itching, burning, or discomfort?
    - Pain during intercourse?
    - Any recent changes in bowel or bladder habits?
    - Any oral or anal sex?
    - When was the last time the new partner had sex with someone else?
- Medical History:
  - LMP: 2 weeks ago.
  - Pregnancy test: Negative.
  - Allergies?
  - Past STIs?
  - Any chronic medical conditions?
  - Current medications?
- Social History:
  - Sexual activity (number of partners, history of unprotected sex).
  - Substance use (tobacco, alcohol, drugs).
  - Living situation.
  - Risk of intimate partner violence.
O (Objective):
- Physical exam: Pelvic exam performed. Visual inspection of vulva, vagina, and cervix.
- POCT (Point-of-Care Testing):
  - Wet mount: To identify trichomoniasis, bacterial vaginosis, or yeast infection. Rationale: Visual examination of vaginal discharge under a microscope to identify causative organisms.
  - pH testing: To assess vaginal pH. Rationale: Abnormal pH can indicate BV or trichomoniasis.
  - Chlamydia and gonorrhea testing (NAAT): Rationale: Given the patient's unprotected intercourse with a new partner, these are the most common bacterial STIs. Nucleic Acid Amplification Testing (NAAT) is the most sensitive and specific.
  - Urine pregnancy test.
A (Assessment/Diagnosis):
- a. Appropriate Diagnosis: Given the patient's symptoms and risk factors, a diagnosis of chlamydia or gonorrhea is highly suspected, pending test results.
- b. Differential Diagnoses:
  - Trichomoniasis
  - Bacterial vaginosis
  - Candidiasis
  - Cervicitis
P (Plan):
- a. Prescriptions: Assume chlamydia is positive: Azithromycin 1g orally in a single dose.
- b. Treatment Guidelines and Side Effects:
  - Azithromycin: Can cause nausea, vomiting, diarrhea.
  - Partner treatment is essential to prevent reinfection.
  - Abstinence from sexual activity for 7 days after treatment completion and until partners are also treated.
  - Follow-up testing is recommended in 3 months.
- c. Patient Education:
  - Importance of completing the full course of treatment.
  - Potential side effects of medication.
  - Abstinence from sex until treatment completion.
  - Partner notification and treatment.
  - Importance of safe sex practices (condoms).
  - Information about other STIs and HIV prevention.
  - When to return for follow up testing.
- d. Complications of Non-Compliance:
  - Pelvic inflammatory disease (PID).
  - Infertility.
  - Ectopic pregnancy.
  - Chronic pelvic pain.
  - Transmission to sexual partners.

Sample Answer

Table 1: STI/Vaginal Infection Overview

Infection	Description	Presentation	Causes/Risk Factors	Treatment (CDC)	Additional Info
Candida (Yeast Infection)	Fungal infection	Vulvar itching, thick white discharge, burning, redness	Antibiotic use, diabetes, weakened immune system, hormonal changes	Antifungal medications (fluconazole, clotrimazole)	Not typically sexually transmitted
Bacterial Vaginosis (BV)	Bacterial imbalance	Thin, gray discharge, fishy odor, itching, burning	Multiple sexual partners, douching, lack of lactobacilli	Metronidazole, clindamycin	Not always sexually transmitted
Chlamydia	Bacterial infection	Often asymptomatic, abnormal discharge, pelvic pain, burning urination	Unprotected sex	Azithromycin, doxycycline	Can lead to PID if untreated
Gonorrhea	Bacterial infection	Abnormal discharge, pelvic pain, burning urination, bleeding between periods	Unprotected sex	Ceftriaxone + azithromycin/doxycycline