A 27-year-old woman comes to the office for a routine medical examination. She reports feeling well since her last appointment a year ago. The patient is sexually active with her boyfriend of 5 years. They are monogamous and use condoms consistently for contraception. She has had no malodorous vaginal discharge or abnormal uterine bleeding. Previous Pap tests were normal. The patient describes her relationship with her boyfriend as stable, although they fight about money and she wishes that he were more supportive. She is unhappy with her job as a waitress and would like to go back to school someday. The patient smokes marijuana about once a week and does not use tobacco or other illicit substances. She has 2 mixed drinks and a couple of beers when socializing with friends after work. The patient denies depression and has no suicidal ideation. Temperature is 36.9 C (98.4 F), blood pressure is 118/78 mm Hg, pulse is 76/min, and respirations are 14/min. Pelvic examination reveals clear cervical discharge throughout the vaginal vault; a Pap test is obtained. Which of the following is the most appropriate next step in management of this patient?

Question

A 27-year-old woman comes to the office for a routine medical examination.  She reports feeling well since her last appointment a year ago.  The patient is sexually active with her boyfriend of 5 years.  They are monogamous and use condoms consistently for contraception.  She has had no malodorous vaginal discharge or abnormal uterine bleeding.  Previous Pap tests were normal.  The patient describes her relationship with her boyfriend as stable, although they fight about money and she wishes that he were more supportive.  She is unhappy with her job as a waitress and would like to go back to school someday.  The patient smokes marijuana about once a week and does not use tobacco or other illicit substances.  She has 2 mixed drinks and a couple of beers when socializing with friends after work.  The patient denies depression and has no suicidal ideation.  Temperature is 36.9 C (98.4 F), blood pressure is 118/78 mm Hg, pulse is 76/min, and respirations are 14/min.  Pelvic examination reveals clear cervical discharge throughout the vaginal vault; a Pap test is obtained.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c046_5d1e_8f63_8b079f5432c5_MD0005_00 The most pressing issue to address in this otherwise healthy patient is her use of alcohol. Because frequent alcohol use is common in patients in their 20s, unhealthy use in this age group often goes unrecognized. For women, unhealthy alcohol use is defined as ≥3 drinks on any day, ≥4 drinks in one sitting (ie, binge drinking), or ≥7 drinks per week (men ≥4/day, ≥5/sitting, ≥14/week). Although the patient has not disclosed the frequency of her alcohol use, the number of drinks consumed in one sitting is concerning and warrants further discussion. Screening and a brief counseling intervention for unhealthy alcohol use are recommended for all adults in primary care. For patients who have experienced few or no alcohol-related problems, cutting down is an appropriate goal. Abstinence is the best goal for patients who meet the criteria for an alcohol use disorder or have a contraindication for alcohol use (eg, pregnancy). A brief counseling intervention should be conducted in a nonjudgmental and empathic manner. Components include expressing concern, providing personalized feedback on the patient's substance use and risks, and a collaborative approach to setting goals for change, with an emphasis on patient autonomy and responsibility. (Choice A) This patient has been forthcoming about her substance use so far in the discussion. Obtaining a urine toxicology screen would likely damage the provider-patient relationship, jeopardize the patient's trust, and discourage additional disclosures. (Choice B) Couples counseling is indicated for significant or escalating interpersonal conflict. Although this patient reports arguing about money and wishing her boyfriend were more supportive, her relationship is stable overall. (Choice D) Wet mount microscopy can be used to diagnose the cause of vaginitis and is indicated in patients with vaginal pruritus, erythema, or malodorous discharge-none of which is seen in this patient. Clear cervical discharge throughout the vaginal vault is most consistent with physiologic discharge. (Choice E) Routine screening for chlamydial infection is indicated in all sexually active women age <25 and in asymptomatic women at increased risk for infection (eg, prior sexually transmitted infection, multiple partners). This patient has no risk factors; therefore, testing is not indicated. Educational objective: Screening and a brief counseling intervention for unhealthy alcohol use are recommended for all adults in primary care. Frequent alcohol use is common in patients in their 20s; unhealthy use (eg, binge drinking) often goes unrecognized, making screening especially important. References: Screening for chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/25243785) Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/23698791) The effectiveness of brief alcohol interventions in primary care settings: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/19489992)

A 27-Year-Old Woman Comes to the Office for a Routine