Case Summary: health promotion and disease prevention, where applicable
When constructing your report, use the same format that was introduced (LINK BELOW). Remember to include health promotion and disease prevention, where applicable, with all presentations and patient counseling. Use the format defined above to present your patient in this Discussion Area. In addition, tell the class about your approach and patient care. Use published articles to support your approach. Please follow format from the link https://threadcontent.next.ecollege.com/pub/content/4a9888b1-7084-4fec-8ca4-4911fee0ed7b/SU_NSG6330_W3_A3_Format.pdf Cite any sources using APA format on a separate page. ssignment 4 Grading Criteria Maximum Points Submitted a 3- to 4-page report on Women’s Health Assessment—Part 1. 5 Completed the initial assessment. 2 Provided an appropriate and complete list of differential diagnoses. 2 Used testing, test results, and other findings to support final diagnoses (and ruled out other possible diagnoses). 2 Described a plan that appropriately addresses all actual diagnoses. 2 Provided an evaluation and reflection on the implementation and results. 5 Used correct spelling, grammar, and professional vocabulary and cited all sources using APA style. 2 Total: 20 Subjective Data: Chief complaint: Ms. S.T is a 22 year old pleasant female whom present to the clinic with a chief complaint of burning on urination, green discharge from the vagina, lower abdominal pain and painful sexual intercourse for the past four days. She is concerned that she may have a sexually transmitted disease and is worried and anxious about the treatment. History of present illness: Ms. S.T symptoms had started four days ago and symptoms have worsened over the past four days. She tried to drink cranberry juice to see if it would help because it has helped in the past when she had a urinary tract infection. But it hasn’t helped this time. She denies any numbness, weakness, shortness of breath, chest pain, nausea, vomiting, diarrhea or fevers. Medical history She has a history of yearly UTI but no other relevant history Past surgical history No reported surgical history Review of systems General: Healthy female. Awake, Alert, and answers all question when asked. She denies weight gain and fatigue. Skin: No noted skin abnormalities. Denies any rash or skin changes. Eyes: The patient denies vision or eye abnormities. She wears glasses and sees the eye doctor on a regular basis. Ears: Denies ear discomfort bilaterally. Nose/Mouth/Throat: Denies mouth, nose or throat abnormality. Cardiovascular: Does not report chest discomfort such as chest pain, palpation, and any associated edema. Respiratory: Denies any current cough, shortness of breath or respiratory distress. No reported history of TB. Breast: Brest assessment deferred at this time. Gastrointestinal: Denies any recent vomiting, nausea, diarrhea, heart burn. Genitourinary/Gynecological: Complains of burning on urination, green discharge from the vagina, lower abdominal pain and painful sexual intercourse. She does not practice safe sex with no use of barrier or hormonal methods of protections. Does report having 28 day cycles with regular vaginal discharge. Musculoskeletal: Denies any joint or muscle injury. No reported swelling, stiffness, or fractures. Heme/Lymph/Endo: Denies any hematological, lymph, or endo issues. Neurological: Denies any neurological deficit. Psychiatric: Denies any psychiatric issues. Do not have thoughts of hurting her self of others. Initial Differential Diagnoses: Chlamydial infection, unspecified A74.9 Gonococcal infection, unspecified A54.9 Urinary tract infection, site not specified N39.0 Objective data: Vital signs: BP: 130/65 HR: 64 Resp: 20 Sat: 98% Wt: 155 Ht: 5’9” BMI : 22% Physical exam: General Appearance: Healthy 22 year old female awake, alert, oriented to person, place and time. Skin: No open blisters, skin warm and dry. Skin within define parameters. HEENT Head: Appropriate for body composition. Hair is evenly distributed Eyes: PERRLA. Normally appearing sclera and conjunctivae. EOM intact. Ears: Tympanic membrane is Peary gray with light reflex. Each ear canal patient with positive whisper test. No noted ruptured ear drums. Nose: Nasal mucosas dry with no sepal deviation. Neck: Present with full range of motion. No associated cervical lymphadenopathy or thyromegaly. Oral mucosa: Moist with absent of thrush. All tonsils present. Well maintained teeth. Cardiovascular In no cardiac distress. SR on EKG 64 heart rate. S1 and S2 present. No JVP presented with capillary refill less than 3 seconds Respiratory: No respiratory distress. Symmetric rise and fall of chest wall on patients inspiration and expiration. Respiratory rate 20, unlabored, with absence of shortness of breath. Breast: Assessment differed at this time. Gastrointestinal: Flat abdomen with bowel sounds present in all four quadrants. On palpation soft and non-tender with no noted hepatosplenomegaly. Genitourinary: Burning on urination. Musculoskeletal: Bilateral upper and lower extremities have full range of motion with strength 5/5. Neurological: The patient is oriented, awake, alert. No neurological deficit noted with cranial nerves II-XII intact Psychiatric: The patient does not have any plan to hurt herself or others. No psych history. Laboratory tests done Nucleic acid amplification tests (NAATs): + Chlamydial infection CBC: Pending Sent to outside lab CMP: Pending Sent to outside lab Dipstick Urine: Negative in side clinic Initial impression The patients presents with symptoms that can both be Chlamydia and Gonorrhea infections. From the Nucleic acid amplification tests (NAATs) yielding a positive Chlamydia infection, means that the patient does in fact have an sti. Individuals with Chlamydia may not have any clinical manifestations. Women may present with abnormal vaginal discharge and burning when urinating. Assessment/Diagnosis: Chlamydial infection, unspecified A74.9 Plan and Implementation: The treatment of chlamydia include doxycycline 100 mg two times a day for 7 days for individuals whom are compliant with medication schedules and azithromycin 1 g IM are used for those likely to forget to take their medication (Keefe, 2010). The CDC notes that in a meta-analysis of 12 randomized clinical trials of azithromycin versus doxycycline for the treatment of genital chlamydial infection, found that the treatments of both medications were equally effective where microbial cure rates were 97% and 98%, respectively (Chlamydial Infections in Adolescents and Adults, 2015). Partner treatment: The patient’s partner will require testing and treatment to prevent complication with the conditions. Education: If individuals were to be provided with education concerning the use of condoms and limiting sex partners the incidence of STI transmission can be further reduced within our society. In the study conducted by Kudo (2013) participants were provided with condom utilizing education. Self-efficacy of condom use education incorporated that of using a condom correctly, carrying/purchasing a condom without feeling embarrassed, and using a condom regardless of whom the sexual partner is, all of which provided significant results for participant’s knowledge in regard to the prevention of STI (Kudo, 2013). On that note, if practitioners or any heath care provider were to provide education to individuals early on life, maybe in grade school with sensitivity to age related development and cultural competence with parent’s permission; children /adolescents can begin learning about sexual health and STI prevention earlier rather than later on in life. Practitioner can further stress that the act of performing sexual activates should only be with one person, where having numerous partners leads to increase risk of attaining a STI’s (Buttaro, Trybulski, Bailey, & Sandberg-Cook 2013). Evaluation The patient should follow up within 2 week or earlier if symptoms still continue despite treatment. The patient is further instructed go to the nearest ER if worsening vaginal bleeding or uncontrolled pain. References Buttaro, T.M., Trybulski, J., Bailey, P.P., & Sandberg-Cook, J. (2013). Primary Care: A Collaborative Practice. Digital Bookshelf (4th ed.). Chlamydial Infections in Adolescents and Adults (2015). Centers for disease control and prevention. Retrieved from https://www.cdc.gov/std/treatment/2010/chlamydial-infections.htm Keefe, A. (2010). Management and treatment of STIs: chlamydia. Nurse Prescribing, 8(1), 10- 12. Kudo, Y. (2013). Effectiveness of a condom use educational program developed on the basis of the Information-Motivation-Behavioral Skills model. Japan Journal Of Nursing Science, 10(1), 24-40. doi:10.1111/j.1742-7924.2012.00207.x.
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