iHuman Case Study Juliana Mirabelles painful urinationcervicitis-Latest-2024, Exams of Nursing

Download iHuman Case Study Juliana Mirabelles painful urinationcervicitis-Latest-2024 and more Exams Nursing in PDF only on Docsity! iHuman Case Study Juliana Mirabelles painful urinationcervicitis-Latest-2023 2024 Juliana Mirabelles 25 y/o CC: Pain with urination HPI: 25 year old female p/w 3 day history of dysuria, urinary frequency as well as mucopurulent vaginal discharge. She denies fever, chills, myalgia. She has a previous hx of UTI, smoking, and multiple sex partners with some unprotected sex.The pain is alleviated by a warm bath and increased with standing. Physical exam shows cervical friability. PMHX Allergies: NKDA Other active problems: None Medical, surgical, obstetric: None just dental fillings Preventative health: Last Pap smear negative a few years ago: no Hx of abnormal results Previous screening for STDs Immunizations: No previous HPV vaccination General immunization status: the patient thinks she is up to date. Rx: Oral contraceptive pills (OCP): ethinyl estradiol/drospirenone Ibuprofen for menstrual cramps FHx: Mother: diabetes mellitus (DM) Father: hypertension (HTN), coronary artery disease (CAD), hyperlipidemia Older sister: Alive and well SHx: Works as a consultant; travels frequently Alcohol: 1 to 2 times per week; 4 to 5 drinks per occasion No other substance use Previous-smoker status; approximate 2-pack-year Hx ROS: General- Tired due to lack of sleep related to increased urination Skin/hair/nails- Negative HEENT- Negative Breast- Negative Cardiovascular- Negative Respiratory- Negative Gastrointestinal- Negative Genitourinary- Describes pain with urination and urinary urgency MSK- Negative Hematologic- Negative Endocrine- Negative Neurological- Negative Psychological- Negative Vitals: Temp: 98.6 F Pulse: 64 regular BP: 118/62 Respiration: 12 PE GU: No labial ulcerations or lesions. Vaginal walls pink without excoriations. Bimanual exam without cervical motion tenderness. Differentials: UTI 1. Candida vaginitis- bc the patient had discharge, dyspareunia, and abx use in pmh 2. Vaginosis- cervical friability, vaginitis, and discharge 3. Cervicitis- bc of discharge, dysuria, and urgency in urination. Tests: 1. UA: abnormal, suggestive of UTI, + leukocyte esterase, high wbc, cloudy 2. N. Gonorrhea + 3. Gram stain- gram negative diplococcie 4. Wet Mount- leukocytes present Culture: UTI 1. Patient was started on empiric therapy for UTI with Ceftriaxone and or Azithromycin 2. Contact past sex partners 3. Pap smear 4. Hiv, hpv, syphilis screening 5. Hpv vaccination