Case Study For Burning With Urination And Fishy Discharge Assignment

Case Study For Burning With Urination And Fishy Discharge Assignment

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Patient Information:

Initials: C.B          Age: 22yo      Sex: F      Race:  N/A

S.

CC (chief complaint): “Burning with urination and fishy discharge.”

HPI: The client, C.B. is a 22yo G0P0 who presents to the clinic today. During the clinical interview, the client reports burning with urination and the production of fishy-smelling vaginal discharge, which have persisted for the last 3 days. The client reports having unprotected sexual intercourse with her new boyfriend. She denies having multiple sexual partners.

Location: Urinary tract system

Onset: The last 3 days

Character: Burning

Associated signs and symptoms: N/A

Timing: None

Exacerbating/relieving factors: None

Severity: Not indicated

Current Medications: Daily multivitamins.

Allergies: Denies drug allergies.

PMHx: Her childhood immunizations are up to date.

Soc & Substance Hx: The client is a social drinker. She denies the use of recreational drugs or tobacco.

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Fam Hx: Her mother is alive with a history of breast and hypothyroidism. Her father is alive with a history of HTN, hyperlipidemia, and T2DM. The client’s paternal grandfather is alive with a history of prostate cancer. The client has one sister who is alive with a history of type 1 diabetes. Her only brother is alive with no medical history. Case Study For Burning With Urination And Fishy Discharge Assignment

Surgical Hx: She has an unremarkable surgical history.

Mental Hx: The client reports a history of anxiety and depression disorders.

Violence Hx: She denies a history of physical abuse or violence.

Reproductive Hx: The client uses the Mirena IUD contraception.

ROS:

GENERAL: Denies weakness, or fatigue.

HEENT: Denies scars on the head. Denies visual loss. Denies hearing loss. Denies sneezing. Denies sore throat.

SKIN: Denies itching.

CARDIOVASCULAR: Denies chest discomfort.

RESPIRATORY: Denies shortness of breath.

GASTROINTESTINAL: Denies nausea or vomiting.

NEUROLOGICAL: Denies headache.

MUSCULOSKELETAL: Denies muscle pain.

HEMATOLOGIC: Denies anemia.

LYMPHATICS: Denies enlarged nodes.

PSYCHIATRIC: Reports depression and anxiety.

ENDOCRINOLOGIC: Denies cold or heat intolerance.

GENITOURINARY/REPRODUCTIVE: Reports burning on urination. Reports production of fishy-smelling vaginal discharge. Case Study For Burning With Urination And Fishy Discharge Assignment

ALLERGIES: Denies drug allergies

O.

Physical exam:

General: The client is attentive throughout the clinical interview. She is alert and oriented to places and persons.

Vitals: BP 132/68; P 62; Height 5’ 5”; Weight 148; and BMI 24.6.

• HEENT: WNL
• Neck: Grossly normal lymph nodes
• Lungs/CV: The client’s chest is clear to auscultation
• Breast: Normal breast exam results
• Abd: Suprapubic tenderness was detected on examination
• Cervix: Smooth, firm, and green discharge seen
• VVBSU: WNL
• Uterus: Non-tender and mobile
• Adnexa: WNL

Diagnostic results:

Microscopic evaluation of vaginal fluid indicated trichomonas

A.

Primary and Differential Diagnoses

1. Urinary tract infection (UTI) – Primary diagnosis
2. Bacterial vaginitis,

• Trichomonas vaginalis,

1. Chronic prostatitis, and

            UTI qualifies as the client’s primary diagnosis. In female adults, UTI is characterized by a burning sensation or pain with urination, frequent urination, and the production of dark cloudy urine (D’Ancona et al., 2019). The client reports burning urination and suprapubic tenderness were detected on examination, qualifying for UTI diagnosis. The first differential diagnosis for this client is Bacterial vaginitis, which is characterized by an abnormal vaginal discharge, itching around the vagina and vulva, and burning with urination (Vidyasagar, 2021)Case Study For Burning With Urination And Fishy Discharge Assignment. The client reports burning with urination and fishy-smelling discharge, qualifying for this diagnosis. However, this condition was ruled out since the client denies itching, which is a significant symptom. Trichomonas vaginalis is another potential diagnosis for this client. This condition is characterized by itching, redness, and burning of the genitals; discomfort while peeing; and foul-smelling vaginal discharge (Tompkins et al., 2020). The client reports burning with urination and fishy-smelling discharge, qualifying for this diagnosis. Nonetheless, this condition is ruled out due to the absence of itching, redness, and burning of the genitals. The last differential diagnosis for this client is chronic prostatitis, which is characterized by a burning sensation or painful urination, difficulty urination, frequent urination, cloudy urine, blood in the urine, and pain in the abdomen (Brehm et al., 2023). The client reports burning with urination, qualifying for this diagnosis. However, chronic prostatitis is ruled out due to the absence of other pertinent symptoms, including difficulty urination, frequent urination, cloudy urine, blood in the urine, and pain in the abdomen.

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The client’s urine sample should be examined under a microscope to detect bacteria. The client should be prescribed Ciprofloxacin (Cipro) 500 mg PO q12h. Ciprofloxacin is preferred due to its efficacy in treating UTIs in female adults (Wagenlehner et al., 2018)Case Study For Burning With Urination And Fishy Discharge Assignment. Additionally, the client should be educated to increase fluid intake so that she can urinate frequently and flush bacteria from the urinary tract system. The client should return to the clinic after two weeks to enable the healthcare provider to monitor her progress. Additionally, I agree with the preceptor’s treatment of this patient since antibiotics are effective in treating UTIs in female adults. From this case, I learned that differential diagnosis is the most effective technique for ruling out conditions with overlapping symptoms. In a similar patient encounter, I would perform a bacteria culture test to determine the bacteria causing the infection. The client has a new boyfriend and engages in sexual intercourse without protection. Thus, her health promotion and disease prevention would involve educating the client about the significance of using barrier methods during sexual intercourse, reducing the risk of contracting sexually transmitted diseases.

References

Brehm, T. J., Trautner, B. W., & Kulkarni, P. A. (2023). Acute and Chronic Infectious Prostatitis in Older Adults. Infectious Disease Clinics, 37(1), 175-194.

D’Ancona, C., Haylen, B., Oelke, M., Abranches‐Monteiro, L., Arnold, E., Goldman, H., … & Standardisation Steering Committee ICS and the ICS Working Group on Terminology for Male Lower Urinary Tract & Pelvic Floor Symptoms and Dysfunction. (2019). The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction. Neurourology and urodynamics, 38(2), 433-477.

Tompkins, E. L., Beltran, T. A., Gelner, E. J., & Farmer, A. R. (2020). Prevalence and risk factors for Trichomonas vaginalis infection among adults in the US, 2013–2014. PloS one, 15(6), e0234704.

Vidyasagar, V. (2021). Estimation of incidence of Aerobic vaginitis in women presenting with symptoms of vaginitis. Indian J. Obstet. Gynecol. Res, 8, 82-85.

Wagenlehner, F., Nowicki, M., Bentley, C., Lückermann, M., Wohlert, S., Fischer, C., … & Dalhoff, A. (2018). Explorative randomized phase II clinical study of the efficacy and safety of finafloxacin versus ciprofloxacin for treatment of complicated urinary tract infections. Antimicrobial agents and chemotherapy, 62(4), e02317-17.

GYNECOLOGIC HEALTH

Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, diagnostic approaches, as well as the development of treatment plans.

For this Case Study Discussion, you will review a case study scenario to obtain information related to a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop treatment and management plans.

To prepare: Case Study For Burning With Urination And Fishy Discharge Assignment

• By Day 1 of this week, you will be assigned to a specific case study (down below) scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your case study assignment from your Instructor.
• Review the Learning Resources (down below) for this week and pay close attention to the media program related to the basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources.
• Carefully review the clinical guideline resources specific to your assigned case study.
• Use the Focused SOAP Note Template (down below) found in the Learning Resources to support Discussion. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your SOAP note. This will help you develop your differential diagnosis and additional questions.

Please post your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations. Your differential diagnosis, additional questions, additional diagnostic tests and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment

Please note that the SOAP note is only for your purposes to come up with the directions on the assignment.  No reflection needed.  I am not grading your SOAP note.

The above are the directions for the assignment.  Please recall what a focused SOAP note is.  You are only to focus on the CC.  Yes, there is additional information provided in these case studies, however, as a provider you are to only focus on the CC.  If there are additional tests you can think of, then include.  There may not be.  What else do you need to ask as the detective of the patient’s CC?  There should only be one primary diagnosis (what you think the diagnosis is)  and 1-3 differential diagnosis (other potential diagnosis) listed.  Don’t overthink and use your critical thinking.  Remember this is a women’s health course. Case Study For Burning With Urination And Fishy Discharge Assignment

Case Study
Charlene Baja is a 22-year-old G0P0 presents to the clinic today for burning with urination and fishy
discharge for 3 days. She states she has a new boyfriend and they are having unprotected intercourse.
She denies any other partners besides him. Her medical history is remarkable for anxiety and
depression. Her surgical history is unremarkable. Her social history includes social alcohol, but she
denies tobacco and any recreational drugs. She has no known drug allergies and takes a multivitamin
and uses the Mirena IUD contraception. Her health history reveals that her mother is alive with breast
cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her
sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia. Charlene
has one brother with no medical history.
· Height 5’ 5” Weight 148 (BMI 24.6), BP 132/68 P 62
· HEENT: WNL
· Neck: lymph nodes grossly normal
· Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth
upon exam
· Breast: normal breast exam
· Abd: suprapubic tenderness
· VVBSU: WNL
· Cervix: firm, smooth, copious amounts of green discharge present
· Uterus: RV, mobile, non-tender
· Adnexa: WNL
· *microscopic evaluation of vaginal fluid (wet mount) shows trichomonas (motile organisms)Case Study For Burning With Urination And Fishy Discharge Assignment
·

Focused SOAP Note Template

Episodic/Focused SOAP Note Template

 Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example: Case Study For Burning With Urination And Fishy Discharge Assignment

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years)Case Study For Burning With Urination And Fishy Discharge Assignment, and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS: Case Study For Burning With Urination And Fishy Discharge Assignment

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active? Case Study For Burning With Urination And Fishy Discharge Assignment

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ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A.

Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background)Case Study For Burning With Urination And Fishy Discharge Assignment.

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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LEARNING RESOURCES

Required Readings

• Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care(4th ed.). Jones and Bartlett Learning.
  • Chapter 10, “Women’s Health After Bariatric Surgery” (pp. 165 – 171)
• Agency for Healthcare Research and Quality (AHRQ). Intimate partner violence screening: Fact sheet and resourcesLinks to an external site.. https://www.ahrq.gov/ncepcr/tools/healthier-pregnancy/fact-sheets/partner-violence.html
• Fanslow, J., Wise, M. R., & Marriott, J. (2019). Intimate partner violence and women’s reproductive health Links to an external site.. Obstetrics, Gynaecology & Reproductive Medicine, 29(12), 342–350. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.ogrm.2019.09.003
• Lockwood, C. J. (2019). Key points for today’s ‘well-woman’ exam: A guide for ob/gynsLinks to an external site.. Contemporary OB/GYN, 64(1), 23–29. https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=134229869&site=ehost-live&scope=site&authtype=shib&custid=s6527200 Case Study For Burning With Urination And Fishy Discharge Assignment

CLINICAL GUIDELINE RESOURCES

• American College of Obstetricians and Gynecologists (ACOG)Links to an external site.. (2020).  https://www.acog.org/
• American Nurses Association (ANA)Links to an external site.. (n.d.). https://www.nursingworld.org/
• Centers for Disease Control and Prevention. (CDC)Links to an external site.. (n.d.). https://www.cdc.gov/
• HealthyPeople 2030. (2020). Healthy People 2030 FrameworkLinks to an external site.. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework
• The American Association of Nurse Practitioners (AANP)Links to an external site.. What’s happening at your association. (2020). https://www.aanp.org/ Case Study For Burning With Urination And Fishy Discharge Assignment