campell nancy/Nancy Campbell iHUMAN CASE STUDY (Pain with urination, Exams of Nursing

Download campell nancy/Nancy Campbell iHUMAN CASE STUDY (Pain with urination and more Exams Nursing in PDF only on Docsity! QUESTIONS AND ANSWERS Exam campell nancy/Nancy Campbell iHUMAN CASE STUDY (Pain with urination TESTED AND CONFIRMED A+ ANSWERS Nancy Cambell 25 ylo 5'5" (165 cm) 135.0 lb (61.4 kg) Reason for encounter Pain with urination Submitted on 01/25/2022 15:52:44 Case authored by: E. Allison Lyons, MD Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats? Do you experience chest pain discomfort or pressure; pain/pressure/dizziness with exertion or getting angry; palpitations; decreased exercise tolerance; or blue/cold fingers and toes? Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or ‘sputum production? Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, or bloating? Do you have problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, or hip pain? { Er ‘Show Dialogue { Well I'm a bit worn out from having to get up and pee all the time. I's hard to get a good night's sleep. What else was it that you asked? That's quite a long list, but no, none of that. No. Whoa. Blood in my stools or vomiting nasty stuff? No. None of that. No Hx Notes Cree]  * blood pressure ‘© genitourinary female exam Pertinent positive and negative findings in this case include the following ‘Mucopurulent discharge from cervical os Cervical friability No labial lesions on skin exam No vaginitis on exam No inguinal lymphadenopathy No cervical motion tenderness Normal abdominal exam A thorough, systematic gynecological exam should become automatic. Components include: © External visualization © Speculum exam © Collection of pertinent specimens for laboratory evaluation © Bimanual exam © Rectal exam inspect skin overall The skin exam is important to check for lesions associated with certain STIs, and to check for fever. palpate abdomen The abdominal exam is essential to the evaluation of any gynecological concern. In addition to evaluating the patient's current complaints, you are also looking for physical signs of any progression of disease. pulse respiration temperature © Not Required, Not Inappropriate * auscultate heart © You performed the simulation correctly. © Your documentation was correct. * cognitive status © height * SpO, © weight X Missed ‘© auscultate lungs © You did not auscultate all the locations. © You documented left lung and right lung correctly ‘© percuss back and spine It concerned about a possible UTI, assessing for CVA tenderness, as this could indicate a possible ascending infection, i.e., pyelonephritis. rot  Organize Findings | Your Findings Case Findings Write Key Finding MsAP Key Finding MSAP Relation Problem Relation . " Statement Mucopurulent vaginal discharge MSAP Pair/ourning with urination x3 days MSAP SVSGE Sa THRSTY OSGUTST | RELATED Select Vaginal discharge RELATED Problem a! Multiple sexual partners RELATED Categories 19° Multiple male sexual partners RELATED pueden RELATED Select No protection against STI’s during RELATED - = Differential © sexual encounters Cervical friability RELATED Diagnosis“ Mucopurulent discharge issuing from RELATED _History of recurrent UTI UNKNOWN Rank cervical os Cigarette smoker UNKNOWN Differential Diagnosis Feedback Select Tests The medical problem list you have compiled should be a list that includes everything that is out of the ordinary about this patient, even when it is not a "problem" in the true sense of the word. In this case, the most significant active problem (MSAP) is the mucopurulent vaginal discharge. What is the typical reason for a vaginal discharge? Is there anything in her sexual history that would put her an increased risk for an infectious process? The gender of partners and the nature of sexual intercourse (j.e., vaginal, anal, oral) are important questions that could influence your differential. Also, it is always important to determine whether contraception was used and if so, what type. In reviewing the problem list, how does her dysuria and urinary frequency fit with the vaginal discharge? Is it possible for @ patient to have more than a single presenting disease? How does her previous history of recurrent UTI relate to her current presentation? Is there anything in her PMH that might increase or lower her risk for certain disease etiologies? What about family history? thorough genitourinary exam must be performed for any patient presenting with the complaint of vaginal discharge. This exam should include an external exam, vaginal exam, speculum exam, and bimanual exam. How would a normal or abnormal exam influence your differential? Evaluation of the vaginal mucosa for inflammation or scarring and examination of the cervix for sloughing or evidence of inflammation can help one narrow the differential. All fluid samples should be evaluated microscopically at the completion of the physical exam. rr  Organize . . Key Your Differential Diagnoses Findings ir Legend: @ Correct X Missed € Extraneous Write Problem © urinary tract infection (UTI) ‘Statement bacterial vaginosis Select Problem X candida vaginitis Categories X ceri —  Organize Key Your Differential Ranking Findings @ Correct € Incorrect Write Problem Differential Your Your Your Statement Diagnosis Lead Graded Alt Graded MNM Graded Select bacterial Problem | vaginosis © o;e/9a Cate ategorieS candida ° ele Select vaginitis Differential cewicitis © @ | O a c Diagnosis. urinary Rank in} tract O° © e a e Differential infection Diagnosis (UTI) Select ra Feedback The initial differential for this patient's clinical presentation includes the following diagnoses: * Bacterial UTI * Vaginitis © Cervicitis Although a UTI could be present with dysuria and increased urinary frequency, vaginal discharge is rarely associated with UTIs. On the other hand, cervicitis due to the bacteria Neisseria gonorrhea and Chlamydia trachomatis is often associated with urethritis. itis important to remember that bacterial UTIs can have long-term consequences if not treated in an appropriate and timely manner. These complications include pyelonephritis and systemic infection. Vaginitis and cervicitis is often very difficult to differentiate based on history alone; often patients will describe vaginal discharge with both conditions. In addition, several of the causative agents for both are associated with risky sexual behavior. The key for the diagnosis lies in the physical exam, which is why the speculum and manual exam are important to this case. A patient with prominent vaginitis will have visible changes in their vaginal mucosa. On the other hand, a patient with normal-appearing vaginal mucosa but a friable cervix is more likely to have cervicitis. The speculum exam is also very helpful for differentiating between many of the causative factors of vaginitis. The microscopic exam can help differentiate between many causes of vaginitis, including candida, trichomonas vaginalis, and bacterial vaginosis. Based on this patient's physical-exam findings of cervical friability and discharge from the os, cervicitis is the most likely diagnosis for this patient's presentation. The 2 leading causes of cervicitis in a sexually active female are gonorrhea and chlamydia which should inform your testing strategy. Gonorrhea is often symptomatic in males, and usually asymptomatic in females. It can present with symptoms of urethritis and/or cervicitis. Without ascending infection, the patient would not have fevers, chills, or other systemic symptoms. Gonorrhea transmission is also associated with many of this patient's risk factors: multiple partners, intercourse while under the influence of alcohol, and failure to use barrier protection (e.g., male condom). Chlamydia, trichomoniasis, and bacterial vaginosis can also present with similar symptoms. Chlamydia, which is often initially asymptomatic, can be associated with long-term consequences if untreated: ascending infection and infertility. Bacterial vaginosis, trichomoniasis, and candida are usually symptomatic infections involving the vaginal mucosa. Trichomoniasis is transmitted sexually and requires treatment of all partners, as well. The behaviors associated with the acquisition of trichomoniasis or bacterial vaginosis are associated with a patient's increased risk for other STIs: HIV, HepB, and HPV. rr}  Organize Key Feedback Findings @ Correct XMissed € Extraneous Write : Problem | bacterial vaginosis Statement X vaginal wet mount/vaginal smear Select C cervical swab/Gram stain eben potassium hydroxide (KOH) preparation test Categories candida vaginitis ee © potassium hydroxide (KOH) preparation test Differential Diagnosis | _€ cervical swab/Gram st Rank cervicitis Differential X Neisseria gonorrhoeae culture Diagnosis Chlamydia culture € vaginal wet mount/vaginal smear € complete blood count (CBC) urinary tract infection (UTI) X urinalysis (UA) @ urine culture complete blood count (CBC) rrr}  ar | Summary Exercises Cn References Ceres ous aca conic DoE ae Ce Case Summary Learning objectives At the conclusion of this case, you should be able to do the following ‘Identify the risk factors for acquiring a sexually transmitted infection (STI) Describe the key elements for evaluating a patient with vaginal discharge, including microscopic evaluation, and laboratory evaluation. Identity possible organisms/infections that can cause vaginal discharge, including gonorrhea, chlamydia, bacterial vaginosis, trichomoniasis, and candida vaginitis. Describe the microbiology of the various organisms that cause vaginal discharge. Describe definitive treatment of gonorthea and empiric treatment of chlamydia. List the common infections that can cause urethritis. Explain the pharmacology of the various antibiotics used to treat STIs. Clinical pearls Chlamydia is a very common infection with 1.2 million cases reported to the CDC each year, and an estimated actual incidence of 2 to 3 million new cases per year. Screenings of females less than 25 years of age have shown that 5% of asymptomatic sexually active females are infected with chlamydia. Studies have also shown that up to 90% of all infected females are asymptomatic. Chlamydia can carry serious long-term consequences, including infertility due to involvement of the uterus or fallopian tubes. In addition, such infections can cause a locally and/or systemically disseminated disease that can cause intra-abdominal abscesses (tubo-ovarian abscesses), perihepatitis, inflammatory arthritis, or other systemic infections. Gonorrhea, though stil a common STI, has been decreasing in incidence over the past several decades. Currently, gonorthea predominantly affects young, nonwhite, unmartied, less educated members of urban populations. There were estimated to be 300,000 new cases in 2008. Gonorrhea transmission from men to women is disproportionately high, with an average transmission risk of 40-60% per 1 unprotected vaginal-intercourse encounter. ‘Complications related to gonorrhea include endometritis/salpingitis (10-15% of untreated cases), tubo-ovarian abscess, bartholinitis, perihepatitis (though this is more common with chlamydia), disseminated gonococcemia with skin lesions, tenosynovitis, arthritis, and endocarditis, Cervical discharge without evidence of vaginitis is likely due to chlamydia or gonorrhea. Organisms responsible for cervical discharge with vaginitis can include trichomonas vaginalis and those bacteria (poorly defined) associated with bacterial vaginosis. Simple gram-stain or wet-mount lab tests can help differentiate between these bacterial organisms. Gonorrhea Chlamydia BV Trichomonads Candida pH Normal Normal >45 >45 Normal (4.0-4.5) Aare Negative Negative Positive Positive Negative PMNs with Wet Increased PMNs —_—increased PMNs Clue cells> motile trichomonads Negative mount 20% (60%) KOH Pseudohyphea Moro Negative Negative Negative Negative (om) Gram Gramnegative _ intracytoplasmic Gram negative stain _diplococci GNR rods sTenomenats Negative BY, trichomoniasis, chlamydia, and gonorrhea increase a patient's chance of contracting HIV. Basic-science pearls Gonorrhea is caused by the bacterium Neisseria gonorrhoeae, a gram-negative diplococcus with several outer surface proteins that allow the bacteria to attach to and invade columnar epithelial cells; such attachment initiates phagocytosis. This protein is also responsible genetic competence. The opacity (outer) protein allows gonorrhea adherence to PMNs, while the porin protein comprises > 50% of the outer surface proteins and is responsible for the gonorrhea serotype. Gonorrhea's antibiotic resistance is due to a single-step mutation that leads to a high level of resistance. This is why gonorrhea has become resistant to multiple classes of medication so quickly. Chlamydia is seen as an intracytoplasmic inclusion by direct fluorescent antibody testing. It is a non-motile, gram- negative, obligate intracellular bacterium that survives in 2 morphologic forms. One is the elementary body, which is the infectious form and able to survive extracellularly; the second, the reticulate body, is noninfectious but provides replication within cells. Bacterial vaginosis is thought to be related to changes in the vaginal flora caused by a decrease in the normally dominant hydroxide-producing lactobacilli. Various "environmental factors" decrease lactobacilli in the vaginal flora; this allows for a predominance of gram-negative rods that create local conditions leading to vaginitis. Causative organisms are thought to include Gardnerella vaginalis, Prevotella species, Porphyromonasspecies, Bacteroides species, Peptostreptococcus species, Mycoplasma hominis, Ureaplasma urealyticum, and Mobiluncus. Patient disposition The patient received ceftriaxone and azithromycin in the medical office. She returned for follow-up in 1 week with complete resolution of symptoms. At that visit, she had an annual pap smear and completed STI screening. Tests for syphilis and HIV were both negative. The patient had received HepB immunization as a child with evidence of current active titers. She received an HPV vaccination at follow-up, as she is still less than 26 years of age. The patient required assistance contacting all previous partners to notify them of recommended screening and treatment. Her case was reported to the Chicago Department of Public Health Peet ay ree