Case: 20 yo female with 4 day history of dysuria, burning, vaginal itchiness/tenderness. Physical exam reveals multiple 5-10 mm ulcerated lesions, significant mucopurulent discharge, and extreme tenderness.
Tapa: Hearing the words painful ulcerated lesion should trigger every medical student to think about Herpes (and also H. ducreyi). Although we have been clasically taught that diagnosis is confirmed with a Tzank smear, in clinical Emergency Medicine practice, Herpes can be diagnosed clinically.
An important point to remember is that patients can often have more than one disease process occurring at the same time. In this case, the patient's vaginal discharge is likely secondary to gonorrhea and/or chlamydia. Due to vaginal tenderness, an accurate cervical examination could not be performed to assess for PID. If unsure, always ere on the side of treating for PID, rather than vaginitis.
Finally, never forget a pregnancy test!
Work-up: UPT, UA, GC/Chlamydia swabs, Wet prep swabs for trichomonas/BV
Treatment:
Primary Herpes - Acyclovir 400 mg, 5 times/day for 5-10 days
PID (always cover GC and Chlamydia) - Ceftriaxone 250 MG IM x1, Doxycycline100 mg PO x10 days
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