Primary Health of Acute Clients Families Across The Lifespan- Clinical Practicum

Subjective ID: JR is a 36-year-old Hispanic female born 7/18/86. CC: “I have had vaginal discharge with a foul odor for the past few weeks” HPI: JR is a 36-year-old Hispanic female that is here at the clinic today for vaginal discharge with a foul odor for the past two weeks. Patient reports that the vaginal discharge is grayish in color with a fishy odor to it. She states that the odor appears to be stronger after intercourse. JR reports using Summer’s Eve douche, and she reported it helped initially, but the odor came right back. Patient reports no pain just an embarrassing odor that will not go away. JR reports that she is recently divorced and has had a new sexual partner. PMH Medical Problem list: None Surgeries and hospitalizations: None GYN History: LMP 3 weeks ago, cycle 3-5 days without heavy bleeding or any other issues, last PAP was December 2021 with no abnormal results. Age of first menses was age 12, recently divorced with a new sexual partner for the last month, hasn’t used any protection. No history of STI’s. OB History: Gravida: 0 Para: 0 Immunizations: Up to date on all vaccines including flu vaccine given on Nov 1, 2022. Allergies: No drug, food, or environmental allergies. Medications: None Family History: Mother 55 still living with HTN, Father 57 still living with no medical issues, Grandfather passed age 80 from CKD, Grandmother passed age 72 from GI bleed. Chemicals: Drinks socially with friends a few times a week, smokes 1-2 packs of cigarettes a week for the last 5 years, does not use illicit drugs. Diet/exercise/caffeine: Does not follow any specific diet, reports running 1 mile a day 3 times weekly, and she drinks 2-3 red bulls daily for caffeine. Social History: Occupation/relationship/current living situation: JR works as a teacher in the public school system, she lives alone in a single-story home, and is recently divorced. Spiritual/Social Supports: No religious preference, reports friends and family as her social support. Safety: Denies texting and driving, wears her seatbelt while in a moving vehicle, does not own guns. Review of Systems  Constitutional: Denies fever, chills, or weight changes.  HEENT: Patient denies any headaches or recent head injury, denies sinus congestion or drainage. Denies any trouble hearing, ringing in ears or vertigo. She reports that her last dental exam within the last 4 months, and denies any bleeding gums, gingivitis or ulceration to mouth or throat, denies chewing or swallowing difficulties.  Cardiovascular: Denies any hypertension, chest pain, heart palpations, or swelling to extremities.  Respiratory: Denies any wheezing, SOB, or sputum production.  Gastrointestinal: Denies any abdominal pain or changes in stool patterns.  Genitourinary: Denies any burning with urination or blood in urine, reports vaginal discharge refer to HPI.  Women: Refer to PMH and HPI.  MSK: Denies muscle pain or joint stiffness.  Integumentary/Breast: Denies any non-healing sores, or rashes. Denies lumps in breast or discharge from nipples.  Neurologic: Denies any changes in memory, seizures, or ataxia.  Psychiatric: Denies any trouble sleeping or depression.  Endocrine: Denies any thyroid issues, hot and cold intolerance, or DM.  Hematologic/Lymphatic: Denies bruising easily, excessive bruising, clotting disorders, or any swollen lymph nodes.  Allergic/Immunologic: Denies allergies or compromised immune system. Objective Physical Exam: Vital Signs: Blood pressure 122/58, respiratory rate 16, pulse 55, temp 98.7, SPO2 100% RA, weight 123, Height 5’5, BMI 20.5. General survey: JR is alert to person, place, time, and situation. She appears well groomed and well-nourished and does not appear to be in any distress. She maintains good eye contact and answers all questions appropriately. Head: Head round and symmetric, no lesions, or signs of trauma noted. Eyes/Ears/Nose PERRLA noted, no redness or discharge noted to eyes.TM grey pearly color all normal structures intact. No nasal congestion, patent nares, maxillary and frontal sinuses without tenderness. Throat/Neck/Mouth: No inflammation, redness, or exudate of the tonsils noted. Trachea midline, thyroid without nodules, no jugular distension noted. Oral mucosa pink and moist, no ulcers noted. Teeth clean and white without dental carries, gums without inflammation or bleeding. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops noted. Lungs: Lungs clear, no SOB, wheezing, rhonchi, or crackles noted. Abdomen: No tenderness or masses, active bowel sounds noted. Lymph: No swelling to lymph nodes. Skin: No rashes, skin warm, dry, and intact. Genital: Discharge, grey and thin consistency with fishy odor noted on pelvic exam, with positive whiff test, and pH 9.0. Clue cells also seen on microscopic exam. Neurologic: Alert and oriented, steady gait, speech clear, and moves all extremities without difficulty. Assessment: Differential Diagnosis 1) Bacterial Vaginosis ruled in because gray discharge with foul odor, positive whiff test, pH 9.0, and clue cells on microscopic exam [B96]. 2) Trichomoniasis ruled out because no reported abdominal pain, dysuria, or pruritus [A59.9]. 3) Chlamydia ruled out because no reports of dysuria, frequency, or urgency with urination [A74.9]. Final DX: Final diagnosis is Bacterial Vaginosis [B96]. Plan: -Diagnostic Plan: 1) Gram stain to check the concertation of lactobacillus. 2) Amsel’s diagnostic criteria which need to be three or more of the following clinical criteria: Vaginal pH > 4.5, presence of clue cells on microscopic exam, white or gray discharge, and positive whiff test. (CDC, 2021; OWH, 2022) Therapeutic Plan (meds): 1) Metronidazole 500mg PO BID for 7 days, dispense 14 pills (Cash et al., 2021). -Referrals: 1) Refer to gynecology if unresponsive to therapy. -Education and Follow up Plan: 1) Education on BV being associated with adverse pregnancy outcomes. 2) Education on treating sexual partners. 3) Education on taking full course of medications for diagnosis. 4) Educate on medication safety during pregnancy. 5) Education on drinking alcohol while taking Metronidazole. 6) Education on avoiding use of feminine products such as douches, avoiding soaps when washing, practice of wiping front to back, to wear cotton underpants, limiting the number of sexual partners, and the potential increase of recurrence after initial infection 7) Follow-up visits aren’t typically required, unless the infection is persistent or continuously recurring. (Cash et al., 2018; CDC, 2021).