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NR602 - Week 7 iHuman Juliana Mirabelles (GU), Assignments of Nursing

iHuman case Juliana Mirabelles Guaranteed Success Reason for Encounter: Pain with urination

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Download NR602 - Week 7 iHuman Juliana Mirabelles (GU) and more Assignments Nursing in PDF only on Docsity! lOMoAR cPSD|3013804 lOMoAR cPSD|3013804 iHuman Screenshots included in this document Reason for Encounter: Pain with urination Juliana Mirabelles NR602 - Week 7 iHuman Reproductive Health Good Questions - 98% 1. How can I help you today? I have been burning when I pee. I was worried I had another bladder infection, but these symptoms are a little different than the symptoms I had with my last UTI. 2. Do you have any other symptoms or concerns we should discuss? Yes. I also have vaginal discharge. 3. When did your pain/discomfort with urination start? About 3 days ago. 4. Does anything make your pain/discomfort with urination better or worse? Soaking in a warm bath helps. 5. How severe is your pain/discomfort with urination? Makes me not want to go, even though I have to! 6. Have you had problems with pain/discomfort with urination like this before? Yes, with my bladder infection last year. But this seems different. 7. Is your pain/discomfort worse with the start or end of urination? Worse when starting, but it doesn’t really let up 8. Do you feel when you need to urinate that you need to urgently? Urgent. Oh, I know what that’s like. I remember I had that bladder infection, when I had to go I literally had to RUN to the bathroom. I haven't noticed that so much with this. 9. Has there been a change in your urination frequency? Well, yeah. Seems like I feel I have to go every 1 0 to 15 or 20 minutes, but I resist due to the pain. 10. Is your urine pink or red in color (blood in urine)? Haven’t seen any. 11. What is the appearance, smell, texture, and quantity of the vaginal discharge? Oh boy. .. I hate having to answer these questions. Yellow, kind of mucousy, kind of creamy. Not really too smelly. 12. Do you have vaginal discomfort or itching? No 13. Have you had vaginal discharge/discomfort like this before? I’ve had yeast infections before, but this is different. 14. Have you been having fevers? No, not really. 15. Are you sexually active? Yes, I am 16. Do you have pain with intercourse? No, but I haven’t had sex since this all started. 17. Are you having or have you had unprotected sex? I’m on the pill, so I guess I’m protected that way. For STD’s not so much. 18. Have you had any sexually transmitted infections? Not that I know of. 19. Do you have more than one sexual partner? Yes 20. Do you have new or multiple sexual partners with similar symptoms? Well, no one has told me he has any problems. 21. Do you use precautions to prevent the transmission of sexual infections? Nothing other than the pill 22. Do you have genital sores or discharge? No sores, but we were talking about the other. 23. When did your last period begin? About two-and-a-half weeks ago. 24. Do you have bleeding between your menstrual cycles? No 25. Are you taking any OTC or herbal medications? Yeah, sometimes take ibuprofen with my period. You know, like for cramps and headaches. 26. Any new or recent changes to your medications? No changes. 27. Do you have allergies? Not that I know of. 28. Are your immunizations up to date? I think so lOMoAR cPSD|3013804 Review or Systems (29) General: Denies fatigue, unintentional weight loss or gain, fevers, or night sweats. (30) Skin/Hair/Nails: None of any of that. Denies any skin problems including, itchy scalp, skin changes, moles, thinning hair, or brittle nails. Denies breast discharge, lumps, scaly nipples, pain, swelling, or redness. HEENT: None of that. Nothing from the neck up. It’s definitely below the waist. Denies headaches. Denies double or blurred vision or difficulty seeing at night and denies problems hearing or ear pain. Denies sinus problems, chronic sore throats, or difficulty swallowing. Breast: No (31) Cardio: That’s quite a long list, but no, none of that. Denies chest pain, discomfort, or pressure; denies any pain/pressure/dizziness with exertion or getting angry; denies palpitations, denies exercise intolerance, denies blue/cold fingers or toes. (32) Resp: No. Denies shortness of breath, wheezing, difficulty catching your breath, chronic cough, or sputum production. (33) GI: Whoa. Blood in my stools or vomiting nasty stuff? No. None of that. Denies any nausea, vomiting, constipation, diarrhea, coffee grounds in vomit, dark tarry stool, bright red blood in bowel movements, denies any satiety or bloating. GU: Reports burning while urination, increased frequency. Denies blood in urine, and difficulty starting or stopping. (34) Muscu: No. Denies any 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. Hemat: Nope. Denies any bruising, bleeding gums, nose bleeds, or other sites of increased bleeding. (35) Endocrine: Well, I'm here because of my peeing problems. Reports urinary frequency. Denies any heat or cold intolerance, increased thirst or sweating, or change in appetite. Neuro: Nope. Denies dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or tremors. Psych: This is definitely not all in my head. Denies nervousness, depression, lack of interest, sadness, memory loss, or mood changes. Denies hearing voices or seeing things that are not there. Not Good Questions What are the events surrounding the start of pain/discomfort with urination? Well, it's hard to say. Do you have any other symptoms associated with your pain/discomfort when urinating? Well, yeah. I thought I told you about it. Do you have abdominal bloating, back pain, weight gain, or mood changes a few days before your period begins? Not on the pill. lOMoAR cPSD|3013804 Case Problem —• MAX of 55 words JM is a 25-year-old female with a past medical history of UTI’s, who presents to the office with complaints of dysuria x3 days. Associated symptoms include urinary urgency, and yellow, creamy, non-odorus vaginal discharge. She reports more than one sexual partners, denies STI protection. Mucopurulent discharge from the cervical os, and cervix friable were noted on the physical exam. JM is a 25-year-old female with a PMH of UTIs, who presents to the office with complaints of dysuria x3 days. Associated symptoms include urinary urgency, and yellow, creamy non-odorous vaginal discharge. She reports more than one sexual partner and denies STI protection. Mucopurulent discharge from the cervical os and cervix friability noted on PE. History of Present Illness JM is a 25-year-old female who presents to the office with complaints of dysuria x3 days. She reports urinary urgency and frequency. She reports a non-odorous, yellow, mucousy, creamy vaginal discharge. She reports soaking in a warm bath helps provide some relief. Her last menstrual cycle was about two-and-a-half weeks ago, denied bleeding between cycles. She reports sexual intercourse with multiple partners and was not aware of any sexually transmitted diseases. She reports she is on OCP but does not use any STD prevention. She denies blood in her urine, genital sores, and fevers. She reports a history of UTIs, and yeast infections but denied previous STDs. lOMoAR cPSD|3013804 EHR Information PMH: UTI Hospitalization/Surgeries: None Medications: Oral contraception pills (OCP) - Ethinylestradiol/drospirenone, Ibuprofen as needed for menstrual cramps. Allergies: None Preventative: Last PAP smear was 2 years ago, no history of abnormal screening. Negative STD screenings prior. Immunizations: Up-to-date, no previous HPV vaccination Family History: Father - hypertension (HTN), coronary artery disease (CAD), hyperlipidemia (HLD); mother - Diabetes Mellitus (DM); older sister alive and well Social History: Works as a consultant, and frequent travel. Drinks alcohol 1-2 times per week, 4-5 drinks per occasion. Denies recreational drug use. Previous tobacco use, approximate 2-pack-per-year history. lOMoAR cPSD|3013804 Management Plan Diagnostic Test Neisseria gonorrhea PCR: Positive for Neisseria gonorrhea Neisseria gonorrhea culture: Positive for Neisseria gonorrhea Urinalysis (UA): Positive for leukocytes esterase, high WBC, slightly cloudy Urine culture: No bacterial growth Human chorionic gonadotropic (hCG), urine: Negative Saline wet mount: Leukocytes present, no motile flagella or clue cells visualized Chlamydia trachomatis PCR: Negative for Chlamydia species Chlamydia trachomatis culture: No Chlamydia species isolated Herpes simplex virus (HSV) culture and typing: Negative Potassium hydroxide (KOH) preparation test: Negative for Candida HIV 1 and/or 2 antibody, blood: Negative Medication Ceftriaxone - Rocephin, 500 mg, intramuscularly, once Client Education Gonorrhea is a sexually transmitted disease (STD) that is caused by the bacteria Neisseria gonorrhoeae, which infects the lining of the urethra, cervix, rectum, or throat, or the membranes that cover the front part of the eye (conjunctiva and cornea). Preventative measures such as the use of condoms will help lower your risk of getting an STD. You can pick up free condoms at the front desk when you check out or at your local health department. You should abstain from having sexual intercourse until your symptoms have resolved or for at least 7 days. STDs are spread by unprotected anal, vaginal, and/or oral sex, through contact with the skin, bodily fluids, or sores of an infected person. Because you have had more than one sexual partner you will need to contact anyone with whom you have had unprotected sexual relations within the last 2 months, including vaginal, anal, &/or oral sex, and notify them of your positive result. They will need to be treated with antibiotic therapy also. Before engaging in a sexual relationship with a person it is important to have open and honest communication about your sexual health history. It is important to get yearly STD screenings. Discussed the importance of the HPV vaccine Follow-up Return visit in 3 months for repeat Neisseria gonorrhea testing, or sooner if symptoms worsen. If you develop a fever, joint pain, heavy uterine bleeding, or severe abdominal pain this would warrant additional medical treatment. Untreated gonorrhea can be life-threatening and place you at an increased risk for HIV. Centers for Disease Control and Prevention. (2020). Just diagnosed? U.S. Department of Health & Human Services. Centers for Disease Control and Prevention. (2021). Gonococcal infections among adolescents and adults. U.S. Department of Health & Human Services. Workowski, K. A., Bachmann, L. H., Chan, P. A., Johnston, C. M., Muzny, C. A., Park, I., Reno, H., Zenilman, J. M., & Bolan, G. A. (2021). Sexually Transmitted infections treatment guidelines, 2021. MMWR Recommendations and Reports: Morbidity and Mortality Weekly Report—Recommendations and reports, 70(4), p. 1-187.
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