iHuman Case Nancy Campbell 25 years old CC: dysuria, Exams of Nursing

Download iHuman Case Nancy Campbell 25 years old CC: dysuria and more Exams Nursing in PDF only on Docsity! iHuman Case Nancy Campbell 25 years old CC: dysuria Campbell Case Summary Ms. Nancy Campbell is 25 years old and comes to the clinic complaining of dysuria that has lasted for three days. Other accompanying symptoms include a creamy vaginal discharge and an increased urination frequency. Ms. Campbell’s symptoms differ from those of UTI as she explains. She is sexually active and have more than one sexual partner and denies having protected sex instead opting for oral contraceptive pills. She denies ever being pregnant before and denies other symptoms. Symptoms presented suit those of cervicitis as described in this presentation. She denies chills, fever and other gastrointestinal symptoms such as nausea and vomiting. 1 1 2 She was treated pharmacologically using Azithromycin 1000mg single dose to be taken orally and ceftriaxone 250mg IM single dose after a series of lab tests. The management plan was accompanied by patient education on abstinence and having protected sex. This illness has a clinical significance as it puts the patient at the risk of getting endometriosis or Pelvic Inflammatory Disease (PID). Other related risks are infertility, chronic pelvic pain and a higher risk of ectopic pregnancy. The pathogens that cause this illness can be sexually transmitted to the patient's sexual partners. According to Butaro, Trybulski, Polgar-Bailey & Sandberg, (2017), there is a high risk of shedding and acquisition of HIV-1 in patients with cervicitis. 2 Patient had urinary tract infection twelve months ago. No known allergies. No medical intolerances No chronic health complications or major traumas. No hospitalization or surgeries are done before. Medications: Oral contraceptive pills. And ibuprofen is taken for headache and menstrual pains. vaccinations are up to date. Family History 5 5 Patient’s mother has type II diabetes and the father is battling high blood pressure, hyperlipidemia and coronary artery disease (CAD). Patient has a sister older than her and is healthy. 6 6 Social History Ms. Campbell is a consultant and hence travels often. She reports to drinking two times a week and she drinks 4 or 5 drinks when she drinks. She previously used to smoke and denies other kinds of drug abuse. Patient has several sexual partners and denies using a condom but rather uses oral contraceptives. 7 7 10 Nose/Mouth/Throat: Patient denies sinus complications, nose bleeds or dysphagia. Denies dental complications, hoarseness or throat pain. Cardiovascular: Denies irregular heartbeats, orthopnea, chest pains and edema. Respiratory: Denies breathing complications, wheezing, coughing or dyspnea. Denies a history of tuberculosis or pneumonia. Review of systems cont’d Gastrointestinal: Patient denies gastrointestinal symptoms such as abdominal pain, constipation or black tarry stool. Denies eating complications, ulcers and hemorrhoids. 10 Genitourinary: Positive for increased urination frequency, creamy vaginal discharge that is yellowish in color. Positive for spotting after sexual intercourse. Denies urine being frothy, denies hematuria. Last PAP test was twenty four months ago and showed normal results. Denies being pregnant before. Breast: Denies tenderness, bumps, skin changes around the breast and lumps. Denies pruritus and retraction of the nipples. Musculoskeletal: Denies pain in the back, joint complications such as swelling or stiffness. Denies a history of osteoporosis or fracture. Heme/Lymph/Endo: Denies blood transfusion, glands that are swollen, heat or cold intolerance and sweating at night. Denies increased hunger or thirst. Neurologic: Denies black-out spells, seizures and syncope. Denies weakness, transient paralysis or paresthesia. Psychiatric: Denies depression, anxiety or insomnia. Denies a history of suicidal thoughts or attempts. Examination 11 11 Vital Signs Temperature: 98.7 F Weight: 135lbs Height: 5’5” Pulse: 66 bpm BMI: 22.5 B/P: 116/64 Resp.: 12 General Ms. Campbell is a healthy-appearing female who is in mild distress due to her condition. Patient is alert and well-oriented. Answers questions in the right way. Her skin is pink, intact, warm and clean with no rashes. Examination cont’d 12 12 Examination cont’d Breast: No changes in skin color around the breasts, nipples with no retraction. Both breasts have striae at the base. No tenderness to palpitation. No masses noted. Genitourinary: Bladder with no CVA tenderness. No case of cervical motion tenderness. No masses. Creamy discharge seen from the cervix. Cervix friable is notable. Musculoskeletal: ROM is full and is visible in all the four extremities upon patient’s movement. Neurological: Clear speech with a good tone. Erect posture, Balance 15 15 16 is stable and gait is normal. 16 Psychiatric: Patient is well-oriented and alert. Properly dressed and keeps a good eye contact. Patient answers questions in the right way. Labs (In-house) Urinalysis: Leukocytes esterase are present, urine is slightly cloudy and a high WBC count Urine culture: No growth of bacteria Neisseria Gonorrhoeae culture: Positive Chlamydia culture: No isolation of species of chlamydia. Cervical swab/gram stain: Negative for diplococci. STD culture: Positive for N. gonorrhea. No trichomonas, negative 17 17 20 This is due to the fact that she has more than one sexual partners and does not use condoms. Patient has been having a yellowish vaginal discharge that is creamy for the last three days. After examination, results show friable cervix with no case of cervical tenderness motion. 20 Symptoms include vaginal bleeding after sex, dysuria, bleeding between periods, painful sex, and creamy vaginal discharge, frequent urination with pain. Differential Diagnoses Pelvic Inflammatory Disease (PID) N73.9 Symptoms include; Lower abdominal pain, painful intercours, bleeding between menstrual cycles Urinary Tract Infection (UTI) N39.0 Symptoms include dysuria, increased urination frequency, pain in the lower abdomen, cloudy urine, fever and chills. Bacterial Vaginosis N76.0 Major symptoms include vaginal discharge, vaginal itching and dysuria. Management Plan 21 21 22 Medications; Azithromycin 1000mg single dose to be taken orally and ceftriaxone 250mg IM single dose. 22 25 the prevention and the management of sexually transmitted illnesses. The article updates the tips periodically based on developing science. The article provides recent updates relevant to the management of STIs. The authors focus on the treatment plans, retests and detection repeat infections and updated vaccines on HPV. In conclusion, the authors of the article state that creation of awareness on STIs is the first step of prevention and management and it is the responsibility of the advanced practice registered nurses to ensure that the public knows the STIs. The authors identify some of the best prevention and management strategies that Ms Campbell could use in managing her condition. Evidence-Based Article 2 Tang (2018) wrote “Updates on Sexually Transmitted Infections: Gonorrhea, 25 Chlamydia, and Syphilis Testing and Treatment in the Emergency Department”. The article focusing on the relevant updates on sexually transmitted illnesses. The author focused on illnesses such as chlamydia, gonorrhea and syphilis. Updates on the testing and treatment of these illnesses are well defined in this article. The article was written to review and define the present guidelines and studies on the screening, diagnosis and treatment of STIs in the emergency department. This article entails information that Ms Campbell can use in ensuring that her illness does not reoccur and how she will be in a position to prevent herself from other sexually transmitted illnesses. Information on screening will be essential in early detection of any STI that she could be suffering from. Evidence-Based Article 3 26 26 “A clinical Conundrum: Chronic Cervicitis” is an article written by Hester & Middleman in 2019 and addresses cervicitis through a case study of a 22-year-old non-pregnant patient who has chronic cervicitis. The authors wrote the article to study the illness through a case study to come up with reliable findings that can be applied in the management and prevention of cervicitis. The authors show that any bacterial regarded to be normal vaginal flora in non-pregnant women such as Ms Campbell should be taken as potential pathogens. This article is relevant as Ms. Campbell is suffering from cervicitis and the authors offer reliable information that can be used in the case of the patient. Evidence-Based Article 4 27 27 30 friability, cervical bleeding and cervical secretions that have elevated leukocytes. The authors have given a recommendation of the treatment options for patients and their partners. Authors 30 31 mention Cefixime 400mg orally taken, azithromycin 1g single dose accompanied by ceftriaxone 250mg IM. This is a relevant article in the case of Ms. Campbell as the mentioned treatment options can be applied to treat her current diagnosis. 31 32 32