Nursing homework cinq

Case Study:
Missed Period

Juanita Morales is a 47-year-old G5P5006, Hispanic female who presents to the office complaining of lower abdominal cramping, and urinary leakage for past day. She states the abdominal cramping, suprapubic, started several hours ago, is sharp, intermittent, and getting more frequent and painful. She tried Motrin but states it did not help. She had a UTI years ago and it was like this, except the incontinence. She has been more tired for the past several months. She relates she stopped getting her period about 8-12 months ago, and relates her menopause was easy. She relates no medical or surgical history. She has no known drug allergies and takes no medications. Social history is negative for alcohol, tobacco, and recreational drugs. Her last exam was several years ago. 

 

Vital signs: temperature 99.1, BP 140/ 82, pulse 88, respirations 12. Height is 5’ and weight 235 lbs. (BMI 45.89). A clean catch urine was obtained, and the urine dipstick showed SG 1.010, trace blood, neg nitrates, neg leukocytes, negative glucose, 3+ protein. She thinks that maybe she had some vaginal spotting several days ago, but nothing since. 

 

Pt relates that she has had some constipation, and increased gas for past several months. She was using NFP for contraception prior to her stopping her period. No other urinary symptoms reported. 

Based on the above case study, 
post the following:

· POST A Focused SOAP NOTE only and describe your case study.  

· Provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.

· Define what you believe is the most important diagnosis. Be sure to include the priority in conducting your assessment.

· Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.

· Also, share with your colleagues your experiences as well as what you learned from these experiences.

PRAC 6552:
Advanced Nurse Practice in Reproductive Health Care

Vaginal Itching and Discharge SOAP Notes

Student’s Name:

Professor’s Name:

Course:

Date:

Patient Information:

J.G, 24 years, female, caucasian

S.

CC (chief complaint): The patient is a 24-year-old female who comes in complaining of itching and gray vaginal discharge; it is thick and looks like cottage cheese.

HPI: 24-year-old female patient presents with a complaint of vaginal itching and grayish discharge that resembles cottage cheese. The onset of symptoms was approximately one week ago. The patient denies having a fever but reports persistent itching and discharge. The patient has no past medical history to report.

Location: Vagina

Onset: One week ago

Character: Itching, Gray, cottage cheese-like discharge

Associated signs and symptoms: None reported

Timing: Symptoms are persistent

Exacerbating/relieving factors: None reported

Severity: Not reported

Current Medications: There needs to be more information provided about any current medications, over-the-counter or homeopathic products being used by the patient. Thus the patient is not under any medication.

Allergies:
No known allergies.

PMHx: tetanus booster shot every ten years. Denies being involved in any surgery.

Soc & Substance Hx: The patient denies using substances such as tobacco, marijuana, cocaine, and vape, but she explains that she consumes alcohol occasionally.

Fam Hx: mother is alive and works as a teacher, and father is also alive and works as a police officer. Paternal grandfather is alive with hypertension and diabetes, while grandmother died in a road accident. My maternal grandfather died from hypertension, and my grandmother died of prostate cancer.

Surgical Hx:
Denies being involved in a surgery

Mental Hx:
The patient denies experiencing depression or having any thoughts of harming herself or those around her.

Violence Hx:
The patient denies experiencing any type of violence.

Reproductive Hx: Patient explains that she is heterosexual and she has a boyfriend who they are sexually active.

ROS:

GENERAL: The patient reports feeling fatigued and having a decreased appetite. There are no reported fevers or chills. No significant weight loss or gain is noted.

HEENT: The patient reports having occasional headaches but no visual changes, hearing loss, or ear pain. The patient denies any nasal congestion, sinus pain, or sore throat.

SKIN: The patient reports itching in the genital area and a thick, gray discharge resembling cottage cheese. No skin rash or lesions are noted.

CARDIOVASCULAR: The patient denies chest pain, palpitations, or edema.

RESPIRATORY: The patient denies shortness of breath, cough, or wheezing.

GASTROINTESTINAL: The patient reports occasional abdominal discomfort but denies nausea, vomiting, diarrhea, or constipation. No changes in bowel habits are noted.

NEUROLOGICAL: The patient denies any numbness, tingling, or weakness. The patient reports occasional headaches but no seizures or loss of consciousness.

MUSCULOSKELETAL: The patient reports no joint pain or swelling. The patient denies any back pain, muscle weakness, or limited range of motion.

HEMATOLOGIC: No significant findings to report.

LYMPHATICS: No significant findings to report.

PSYCHIATRIC: The patient denies any history of depression, anxiety, or suicidal thoughts. The patient reports feeling stressed and anxious about their symptoms.

ENDOCRINOLOGIC: No significant findings to report.

GENITOURINARY: The patient reports burning with urination, which may indicate a urinary tract infection. The patient denies any vaginal discharge or pain.

ALLERGIES: No significant findings to report.

O.

Physical exam:

General: The patient appears fatigued but in no acute distress.

HEENT: Head is normocephalic and atraumatic. The patient’s pupils are equal and reactive to light. Extraocular movements are intact. Ears are without erythema, swelling, or discharge. The nose is without deformities or discharge. The oral mucosa is moist and pink.

Genitourinary: Examination of the external genitalia reveals no erythema, swelling, or discharge. Vaginal walls are without lesions or masses. The patient reports tenderness with palpation of the urethra and a positive leukocyte esterase on urinalysis.

Breasts: No palpable masses or nodules are identified in either breast.

Neurological: Cranial nerves II-XII are intact. Strength is 5/5 in all extremities. The sensation is intact to light touch and pinprick. Reflexes are 2+ and symmetric.

Musculoskeletal: No tenderness, swelling, or deformities are noted on the back or extremities examination.

Hematologic/Lymphatic: No significant findings to report.

Psychiatric: The patient appears anxious but is cooperative and oriented to person, place, and time.

Diagnostic results: The patient’s urinalysis reveals a positive leukocyte esterase, which suggests a urinary tract infection (UTI). A urine culture and sensitivity are ordered to confirm the diagnosis and determine the appropriate antibiotic therapy. In addition, a vaginal swab is obtained and sent for microscopy and culture to evaluate for possible vaginal infections. Based on the patient’s symptoms and physical exam, no further diagnostic tests, such as imaging or blood tests, are needed at this time. However, further evaluation may be necessary depending on the response to treatment and the resolution of symptoms.

A

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Primary and Differential Diagnoses:

1.
Vulvovaginal candidiasis: The patient’s symptoms of itching, thick and curd-like vaginal discharge and absence of fever are consistent with vulvovaginal candidiasis, which is a common fungal infection in women. According to Rosati et al. (2020), vaginal candidiasis can be diagnosed clinically based on symptoms and physical examination findings. However, laboratory testing may be considered in patients with recurrent or complicated infections or if the diagnosis is uncertain.

2.
Urinary tract infection: The patient’s symptom of burning on urination could also be indicative of a urinary tract infection. According to Kumar (2019), a urine culture is a gold standard for the diagnosis of UTI, and antibiotic therapy should be based on the results of susceptibility testing. However, a negative urine culture does not exclude the possibility of a UTI, especially in patients with symptoms suggestive of UTI.

3.
Bacterial vaginosis: Bacterial vaginosis is another common vaginal infection that can present with symptoms such as vaginal discharge and itching. The diagnosis of bacterial vaginosis can be made using clinical criteria, such as the Amsel criteria, or by laboratory testing, such as a gram stain of vaginal fluid (Liu & Yi, 2022).

P.

From this case, it is important to note the importance of a thorough history and physical exam in order to arrive at an accurate diagnosis. It is also important to consider other potential diagnoses, in addition to the most likely ones, in order to rule them out or diagnose them properly.

References

Kumar, A. (2019). Urinary tract infection. 
Infections in Pregnancy: An Evidence-Based Approach, 129.

Liu, H. F., & Yi, N. (2022). A systematic review and meta-analysis on the efficacy of probiotics for bacterial vaginosis. Eur Rev Med Pharmacol Sci, 26(1), 90-98.

Rosati, D., Bruno, M., Jaeger, M., Ten Oever, J., & Netea, M. G. (2020). Recurrent vulvovaginal candidiasis: an immunological perspective. 
Microorganisms, 
8(2), 144.

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