NSG 6020 Week 8 Assignment 4 The Pelvic Examination

39 Sex: Female

SUBJECTIVE

CC: “I have a discharge and vaginal odor.”

HPI: 39 y/o Hispanic female presents to the clinic complaining of a yellowish vaginal discharge with an odor that began about a weeks ago. Reporting some discomfort during sexual intercourse. Patient denies any cramping, vaginal bleeding, indigestion, diarrhea, constipation, and change in stool, hematemesis, urinary frequency, urgency, or hematuria. Patient attempted to treat with Monistat but did not notice any improvement. Onset of symptoms – 13 years old (1st menstrual) Location of symptoms -Vagina NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Medications: Tylenol 500 mg 2 tablets q 6 hours as needed for pain and headaches.

PMH Chlamydia – 2020 Allergies: No known drug, food, latex, or environmental allergies Medication Intolerances: None known Chronic Illnesses/Major traumas None Hospitalizations/Surgeries None NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Family History Mother: Age 60. Hypertension. Father: Age 63. Hypertension Brother: Age 23. No known health problems

Social History Patient lives with boyfriend. Patient report feeling safe in-home environment. Denies smoking or any use of tobacco, as well as substance or drug abuse. Patient drinks 2-3 caffeine beverages a day. Patient drinks socially, wears safety belt

ROS

General Denies fatigue, fever, chills, night sweats, energy level, or lack of appetite. Cardiovascular Denies Chest pain, palpitations, PND, orthopnea NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Skin Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles. Respiratory Denies wheezing, hemoptysis, dyspnea, pneumonia hx, TB.

Eyes Denies blurring, pain, visual changes of any kind. Gastrointestinal Denies Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools. NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Ears Reports pain to bilateral ears. Denies hearing loss, ringing in ears, discharge. Genitourinary/Gynecological Denies Urgency, frequency burning, change in color of urine. Admits to painful intercourse for the last week her with boyfriend. Admits to using condoms sometimes for contraception. Does not use any other method. Last Pap: States last Pap smear normal in January 2021. Breast Self-Exam: Admits to conducting breast self-exam monthly.

Mammogram: States she has never had a mammogram. Menstrual complaints: Denies any menstrual complaints with last LMP two weeks ago. Vaginal discharge: yellowish vaginal discharge with an odor that began about a week ago. Pregnancy history: Denies any pregnancy history. Onset of sexual activity with males at age 17, admits to 3 partners, but the last year only with her boyfriend. She reports menarche at age 13. NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Nose/Mouth/Throat Patient reports rhinitis, hoarseness, and throat pain. Denies Sinus problems, dysphagia, nose bleeds or discharge, dental disease Musculoskeletal Denies Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis

Breast Denies lumps, bumps, or changes Neurological Denies syncope, seizures, transient paralysis, weakness, paresthesia, black out spells

Heme/Lymph/Endo HIV status – negative. Denies bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Psychiatric Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE

Weight   133lbs    BMI 22.7 Temp 97.5 BP 110/75

Height 5.5 Pulse 66 Resp 17

General Appearance 22y/o Hispanic female, very pleasant woman, in no acute distress, seated upright on the examination table, dressed appropriately with good hygiene. Maintain eyes contact during interview and answer all the questions appropriately, Alert, Awake, Oreintedx3. NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Skin Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.

HEENT Head is normocephalic, atraumatic, and without lesions, hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinate’s. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular No chest pain noted. Heart rate is normal at 66, with intact distal pulses. S1 and S2 with S3 noted. No murmur, rubs, or clicks. No edema. PMI found at midclavicular line with no heaves, thrills, or lifts. Capillary refill less than 3 seconds. NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal Soft non- distended abdomen. Active bowel sounds x 4 quadrants. Tympanic percussion sounds x 4 quadrants. Non-tender abdomen with palpation x 4 quadrants. No hepatosplenomegaly appreciated on palpation.

Breast – Symmetric, tender, without mass. No swelling, ulceration, or discharge noted

Genitourinary – Bladder is non-distended; no CVA tenderness. External genitalia without erythema, lesions, or masses. No inguinal adenopathy. No vulvar lesions noted. External genitalia: no lesions noted, vaginal walls pink, pubic hair, scant, shaven. Vagina: Mucosa moist and slightly reddened. Small amount of yellowish vaginal discharge noted. Cervix: pink, w/o lesion or mass. Bimanual exam: lower pelvic tenderness, no palpable uterine or ovarian enlargement. Rectum is appropriate, no evidence of hemorrhoids, fissures, bleeding, or masses. NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological No fine resting tremor of the outstretched upper extremity. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Speech is clear and fluent.

Psychiatric Alert and oriented. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests Pap smear and culture- positive for trichomoniasis.

Special Tests

ASSESSMENT FINDINGS AND PLAN

Differential Diagnosis Candida vaginitis (B37.3) is a vaginal yeast infection that is caused by the organism Candida albican that is a naturally occurring microorganism in the vaginal area. Lactobacillus bacteria keeps its growth in check although if there’s an imbalance in your system, these bacteria won’t work effectively (Martin Lopez, 2015). This leads to an overgrowth of yeast, which causes the symptoms of vaginal yeast infections. Clinically a diagnosis is made by the presence of external dysuria and vulvar pruritus, pain, swelling, and redness (Martin Lopez, 2015). NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Signs also include vulvar edema, fissures, excoriations, and thick curdy vaginal discharge. This is not supported by clinical & physical assessment. Pelvic inflammatory disease (N73.9) is an infection of the upper part of the female reproductive system namely the uterus, fallopian tubes, and ovaries, and inside of the pelvis (Brunham, Gottlieb & Paavonen, 2015). Signs and symptoms, when present may include lower abdominal pain, vaginal discharge, fever, burning with urination, pain with sex, or irregular menstruation. NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Untreated PID can result in long term complications including infertility, ectopic pregnancy, chronic pelvic pain, and even cancer (Brunham et al, 2015). This is not supported by clinical & physical assessment. o   Trichomonas vaginalis (ICD 10 code A59.01) is a common STD and is caused by infection with a protozoan parasite called Trichomonas vaginalis. Common symptoms include itching, burning, redness or soreness of the genitals. A change in their vaginal discharge which can be clear, white, yellowish, or greenish with an unusual fishy smell. The parasite passes from an infected person to an uninfected person during sex. NSG 6020 Week 8 Assignment 4 The Pelvic Examination

In women, the most commonly infected part of the body is the lower genital tract (vulva, vagina, cervix, or urethra (Arab-Mazar & Niyyati, 2015). Culture is the most efficacious test, but newer NAATs are becoming available and will allow more rapid diagnosis. Final Diagnosis- Trichomonas vaginalis (ICD 10 code A59.01) Plan – Further testing – None Medication – Metronidazole 500mg PO BID x 7 days                  Education- Education: Treatment involves both partners taking an oral antibiotic. Instructions are to finish the entire course of antibiotics for treatment, even if the symptoms resolve after a few doses.NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Alcohol consumption should be avoided during treatment with nitroimidazoles. Sexual intercourse should be avoided for 7 days and consistent use of condom should be encouraged, testing for other STDs including chlamydia, syphilis, and HIV and retesting in three months is also recommended (CDC, 2015). Non-medication treatments- None NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Reference

Arab-Mazar, Z., & Niyyati, M. (2015). Trichomonas vaginalis pathogenesis: A narrative review. Novelty in Biomedicine, 3(3), 148-154.

Bastida-Corcuera, F. D., Singh, B. N., Gray, G. C., Stamper, P. D., Davuluri, M., Schlangen, K., . . . Corbeil, L. B. (2013). Antibodies to trichomonas vaginalis surface glycolipid. Sexually Transmitted Infections, 89(6), 467. doi:10.1136/sextrans-2012-051013

Brunham, R. C., Gottlieb, S. L., & Paavonen, J. (2015). Pelvic inflammatory disease. The New England Journal of Medicine, 372(21), 2039.

Centers for Disease Control and Prevention. (2018). Trichomoniasis. Retrieved from https://www.cdc.gov/std/tg2015/trichomoniasis.htm

Martin Lopez, J. E. (2015). Candidiasis (vulvovaginal). BMJ Clinical Evidence, 2015. NSG 6020 Week 8 Assignment 4 The Pelvic Examination

Reply