HPI<\/strong>: Patient 40 years old female, Hispanic, comes to visit for gynecologic examination, complaining of amenorrhea for 2 months, reports irregular periods before.<\/p>\n Past Medical Hx<\/strong>:<\/p>\n \u00a0Essential (primary) hypertension I10<\/p>\n Obesity, unspecified E66.9<\/p>\n Hyperlipidemia E78.1\u00a0<\/p>\n Type 1 Diabetes mellitus with unspecified diabetic retinopathy without macular edema\u00a0E10.319<\/p>\n Pap smear\u00a0<\/p>\n \u00a0Date: 11\/17\/2018; Notes: HPV negative but reactive cellular changes and\/or repair are present, the predominance of coccobacilli consistent with a shift in vaginal flora is present\u00a0<\/p>\n \u00a0Date: 11\/23\/2016; Notes: Normal\u00a0<\/p>\n \u00a0Notes: Normal 2008\u00a0Negative for Cancer of the ovaries; Asthma; Cancer of the breast; Cancer of the lung; Diabetes; Heart failure, systolic; Heart disease (CAD); Cancer of the colon; Heart failure, diastolic.<\/p>\n Menstrual History\u00a0<\/strong><\/p>\n Menstrual information\u00a0<\/p>\n \u00a0Notes: Irregular\u00a0<\/p>\n Pregnancy History\u00a0<\/p>\n Past pregnancy\u00a0<\/p>\n \u00a0Notes: G2 P2 A0 L2<\/p>\n Surgical History\u00a0<\/strong><\/p>\n Cesarean section\u00a0<\/p>\n Social History\u00a0<\/strong><\/p>\n Sexually active\u00a0<\/p>\n Sexually active\u00a0<\/p>\n Employed\u00a0<\/p>\n Children\u00a0<\/p>\n Married\u00a0<\/p>\n Never smoked\u00a0<\/p>\n Negative for: Exercise; Past drug use; Alcohol use\u00a0<\/p>\n \u00a0Family Hx:\u00a0<\/strong><\/p>\n Father: Diabetes mellitus<\/p>\n Mother: Hypertension,<\/p>\n Grandparents: Diabetes mellitus<\/p>\n Allergies<\/strong>: No Know Allergies<\/p>\n Current Medication<\/strong>:<\/p>\n \u00a0Lisinopril 10 mg tab PO daily.<\/p>\n Glargine 40 units at bedtime<\/p>\n Atorvastatin 80 mg tab PO at bedtime daily<\/p>\n Review of systems<\/strong><\/p>\n General\/Constitutional\u00a0<\/p>\n Patient t Reports: Amenorrhea for 2 months, she denies chills and night sweats. She also denies weight loss and weight gain or fever.<\/p>\n HEENT<\/strong><\/p>\n Eyes: Denies swellings, itchiness, blurry vision, discharges. The patient wears glasses.<\/p>\n Head: Denies (pain, vertigo, tinnitus, hoarseness, dysphagia, cough, throat pain, hearing problems, trauma, lump).<\/p>\n Systemic symptoms: Denies (fever, chills). No recently weight loss.\u00a0\u00a0<\/p>\n Neurological: Denies sleeping problems, nausea, vomiting, vertigo, weakness, gait change, dizziness, or headache.<\/p>\n Respiratory: Denies cough, shortness of breath, chest pain, cyanosis.\u00a0<\/p>\n Cardiovascular: Last EKG (atrial fibrillation). The patient denies chest pain, dizziness, SOB, weakness, fatigue, bilateral lower extremity swelling.<\/p>\n Gastrointestinal: Denies abdominal pain, distention, anorexia, diarrheas, nauseas, vomiting, flatulence.<\/p>\n Genitourinary: Pt Reports: Amenorrhea\u00a0for 2 month, She denies increased urinary frequency, blood in the urine, and nocturia.<\/p>\n Endocrinology: Denies: Excessive appetite; Excessive sweating; Excessive thirst; Excessive urination; Heat\/cold intolerance; Hair loss; Excess hair growth<\/p>\n Musculoskeletal: Denies arthralgia, myalgia, or pain to the movement of the joints or muscles cramp.<\/p>\n Integumentary: Denies discomfort and itching in her vagina, denies swollen.<\/p>\n Pt Denies: Skin lump\/mass; Mole changes; Performs monthly self-breast exam; Breast lump\/mass; Breast pain; Nipple discharge; Stretch marks; Varicose veins; Phlebitis\u00a0<\/p>\n Neurological: Pt denies Headaches Pt Denies Numbness\/tingling; Seizures; Tremors; Difficulty walking; Localized weakness Psychiatric. Pt Denies: Anxiety; Depression; Frequent crying; Nervousness; Hallucinations; Memory loss; Sleep problems; Suicidal thoughts\u00a0<\/p>\n Hematologic\/Lymphatic Pt Denies: Easy bleeding or bruising; Anemia; Swollen glands Allergic\/Immunologic\u00a0<\/p>\n Physical examination<\/strong><\/p>\n Weight:\u00a0172 lbs\u00a0\u00a0\u00a0\u00a0\u00a0Temp 98.1 F BP: 132\/86 Height 5\u20192\u201d\u00a0Pulse:82\u00a0Resp: 20<\/p>\n General: The patient is alert and oriented, able to provide accurate information, good eye contact during the interview, cooperative. The patient states a good understanding of the conversation. The patient seems slightly distressed<\/p>\n HEEET Head: Normocephalic, atraumatic, symmetric, no visible or palpable masses, depressions, or scaring. Good hair distribution, good hygiene. No bleeding, no papules, no vesicles.\u00a0<\/p>\n Neck: Trachea in the midline, No neck veins distention. No posterior cervical adenopathy. No carotid bruits and no goiter.<\/p>\n Ears:\u00a0TMs (Pale, gray, translucent appearance, Cone of light and bony landmarks visible) & mobile, hearing intact. Ear canals clear without inflammation or redness.<\/p>\n Nose: Smell sense intact, No external or internal lesions observed. No exudate or secretion. No observed septum deviation.<\/p>\n Eyes: Visual acuity intact 20\/20 with corrective glasses, Eyes symmetric, no blepharitis, no redness clear conjunctiva, no ocular discharge bilaterally. PERRLA<\/p>\n Throat: Gap reflex present, uvula in the midline, Good hygiene, No lesions in soft tissues, no gingival inflammation, no bleeding. Tonsils 2+<\/p>\n Respiratory: Chest symmetric, Tactile fremitus present. thoracic expansion symmetric. No wheezing or crackles sounds.<\/p>\n Breast: No overlying skin changes; No dimpling; No nipple retraction; No masses or lumps; Right breast no palpable masses or lumps; Left breast no palpable masses or lumps; No tenderness; No regional lymphadenopathy<\/p>\n \u00a0Additional comments: US-guided biopsy right breast, showing fibroadenoma, no malignancy was seen. Diagnostic mammogram and ultrasound in 1 year are recommended (August 2021)\u00a0<\/p>\n Skin: Warm to touch, no hyperthermia, Inguinal intertrigo<\/p>\n Cardiovascular: HR regular. No murmur, no thrill, no rubs, No swollen leg. All pulse palpable, no sign of DVT or PAD.<\/p>\n \u00a0Abdomen: Flat, no tender no distended, No scar visible on inspections, soft on palpation. Liver palpable no splenomegaly, no masses, no pain with palpation. Bowel sound present in all quadrant. The patient denies Costovertebral angle tenderness.<\/p>\n Genitourinary:\u00a0No erythema, masses, or lesions detected on the external genitalia. The vaginal mucosa is pink. No blood detected on the stool, which is brown. No inguinal adenopathy or adnexal masses noted. No rectovaginal masses detected.\u00a0Vulva,Vagina,Cervix (Normal appearance); By TV sonogram (Uterus normal size\/shape with normal ovaries)\u00a0<\/p>\n Lymphatic: No visible or palpable adenopathy.<\/p>\n Extremities: Full range of motion in 4 extremities, Pulses present and symmetric. No swelling, no deformities\u00a0<\/p>\n Neurological: All cranial nerves intact. No weakness, no vertigo, or dizziness. Adequate sensation in 4 extremities. Reflexes are +2\u00a0<\/p>\n Assessment and Plan<\/strong><\/p>\n Diagnosis:\u00a0<\/strong><\/p>\n Amenorrhea, unspecified N91<\/strong>. Amenorrhea is the absence of menstruation. Secondary amenorrhea occurs when you\u2019ve had at least one menstrual period and you stop menstruating for three months or longer. Secondary amenorrhea is different from primary amenorrhea. It usually occurs if you haven\u2019t had your first menstrual period by age 16.A variety of factors can contribute to this condition, including birth control use<\/u>, certain medications that treat cancer, psychosis, or schizophrenia, hormone shots, medical conditions such as hypothyroidism, being overweight or underweight<\/p>\n Differential Diagnosis:<\/strong><\/p>\n Hypothyroidism E03.9<\/strong>: Other clinical signs of thyroid disease are usually noted before amenorrhea presents. Mild hypothyroidism is more often associated with hypermenorrhea or oligomenorrhea than with amenorrhea. Treatment of hypothyroidism should restore menses, but this may take several months.<\/p>\n HYPERGONADOTROPIC HYPOGONADISM\u00a0E23.0: <\/strong>Ovarian failure can cause menopause or can occur prematurely. On average, menopause occurs at 50 years of age and is caused by ovarian follicle depletion. Premature ovarian failure is characterized by amenorrhea, hypoestrogenism, and increased gonadotropin levels occurring before 40 years of age and is not always irreversible\u00a0(0.1 percent of women are affected by 30 years of age and one percent by 40 years of age).\u00a0Approximately 50 percent of women with premature ovarian failure have intermittent ovarian functioning with a 5 to 10 percent chance of achieving natural conception<\/p>\n Polycystic ovary syndrome (PCOS) E 28.2<\/strong>: is a hormonal disorder common among women of reproductive age. Women with\u00a0PCOS\u00a0may have infrequent or prolonged menstrual periods or excess male hormone (androgen) levels. The ovaries may develop numerous small collections of fluid (follicles) and fail to regularly release eggs.<\/p>\n The exact cause of\u00a0PCOS\u00a0is unknown. Early diagnosis and treatment along with weight loss may reduce the risk of long-term complications such as type 2 diabetes and heart disease.<\/p>\n \u00a0PLAN<\/strong><\/p>\n Further Testing:<\/strong><\/p>\n \u00a0Pregnancy test.\u00a0This will probably be the first test your doctor suggests, to rule out or confirm a possible pregnancy.<\/p>\n Thyroid function test.\u00a0Measuring the amount of thyroid-stimulating hormone (TSH) in your blood can determine if your thyroid is working properly.<\/p>\n Ovary function test.\u00a0Measuring the amount of follicle-stimulating hormone (FSH) in your blood can determine if your ovaries are working properly.<\/p>\n Prolactin test.\u00a0Low levels of the hormone prolactin may be a sign of a pituitary gland tumor.<\/p>\n Transvaginal ultrasound.<\/p>\n Medication<\/strong>: Treatment depends on the underlying cause of your amenorrhea. In some cases, contraceptive pills or other hormone therapies can restart your menstrual cycles. Amenorrhea caused by thyroid or pituitary disorders may be treated with medications. If a tumor or structural blockage is causing the problem, surgery may be necessary.<\/p>\n Education<\/strong>: Some lifestyle factors such as too much exercise or too little food can cause amenorrhea, so strive for balance in work, recreation, and rest. Assess areas of stress and conflict in your life. If you cannot decrease stress on your own, ask for help from family, friends or your doctor.<\/p>\n Be aware of changes in your menstrual cycle and check with your doctor if you have concerns. Keep a record of when your periods occur. Note the date your period starts, how long it lasts and any troublesome symptoms you experience.<\/p>\n Return to office<\/strong>:\u00a0The patient should return to the clinic immediately if the condition worsens and symptoms persist. Follow-up should be done in two weeks if the condition does not worsen.<\/p>\n References\u00a0<\/strong><\/p>\n DeCherney AH, et al. Current Diagnosis & Treatment Obstetrics & Gynecology.11th ed. New York, N.Y.: The McGraw-Hill Companies; 2013. http:\/\/www.accessmedicine.com\/resourceTOC.aspx?resourceID=788. Accessed Jan. 21, 2014.<\/p>\n Klein DA, et al. Amenorrhea: An approach to diagnosis and management. American Family Physician. 2013;87:781.<\/p>\n Goldman L, et al. Goldman’s Cecil Medicine. 24th ed. Philadelphia, Pa.: Saunders Elsevier; 2012. http:\/\/www.clinicalkey.com. Accessed Jan. 20, 2014.<\/p>\n Reply<\/u> Patient Information:<\/strong><\/p>\n Name:<\/strong>\u00a0KG<\/p>\n Age:<\/strong>\u00a023 y\/o.<\/p>\n Gender:<\/strong>\u00a0Female.<\/p>\n Race:<\/strong>\u00a0Hispanic<\/p>\n Advanced Directives:<\/strong>\u00a0\u00a0Full Code\u00a0<\/p>\n Source:<\/strong>\u00a0Patient\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n Past medical History<\/strong><\/p>\n Chronic Illnesses\/Major traumas: Obesity.<\/p>\n Family Medical History: Mother diagnosed with: Diabetes Mellitus Type 2, 45 y\/o, alive.<\/p>\n Father diagnosed with: Gout, 50 y\/o, alive.<\/p>\n Allergies: None.<\/p>\n Surgery: None<\/p>\n Screening Hx\/Immunizations Hx: TT, 2020. Flu: 2020, Pap smear 2020 (Negative)<\/p>\n Current Medications:\u00a0<\/strong><\/p>\n -Tylenol 500 mg 1tab PO every 6 hours for mild pain\/fever<\/p>\n Social history:<\/strong>\u00a0Patient has high school degree, and she works at a mall for 5 years. She is single and she is sexually active and has history of unprotected vaginal sex with multiple partners. Actually, she lives with her son and her parents, he is 5 years old. The support is her family and denies any needs at this time. She has adequate shelter. She has a sedentary life. She doesn\u2019t have healthy diet. She denies substance abuse, ETOH, tobacco, marijuana or illicit drug ingestion.<\/p>\n Subjective:<\/strong><\/p>\n CC:<\/strong>\u00a0\u201cI had been with foul-smelling vaginal discharged, pain during urination and bleeding after having sex for the last 2 weeks without relief.\u201d<\/p>\n HPI:<\/strong>\u00a0This is a 23-yr. old Hispanic, female who goes to the clinic with c\/o foul-smelling vaginal discharged, dysuria, dyspareunia and bleeding after coitus for the last 2 weeks without relief. Patient denied fever or previous vaginal malodorous. She is sexually active and reports multiple sexual partners, a history of negative result of Papanicolaou tests in the recent past, and recent unprotected vaginal intercourse. She claims poor pain relief with Tylenol 500 mg oral every 6 hours. Also, she denies history of sexually transmitted disease, douching and antibiotic use recently. She informs the vaginal discharge looks like creamy greenish and has foul-smelling odor. She mentions that she feels a sharp pain in the lower abdomen which she rates a 3 out of 10. She refers mild distress related to painful sexual intercourse. Denies abdominal trauma, fatigue, vomit, nausea and diarrhea. She does not present any past medical history. She has not had similar symptoms in the past. The menarche was at 12 y\/o, the LMP: 10\/5\/2020 for 6 days, regular cycle, plus the spots already described, G1T1P1A0L1.<\/p>\n ROS:<\/strong><\/p>\n General:<\/strong>\u00a0She refers weight gain 10 pounds in the last month, denies fatigue, fever, malaise and decreased energy level.\u00a0<\/p>\n Skin:<\/strong>\u00a0She denies healing problems, rashes, bruising, bleeding or skin discolorations, no changes in lesions. She has a mole (birthmark) in her left side of her neck.\u00a0<\/p>\n Eyes:<\/strong>\u00a0She denies changes in her vision, diplopia, blurry vision, no redness or swelling, watering or discharge.<\/p>\n Ears:<\/strong>\u00a0She denies hearing loss, ear pain, ringing in ears, discharge.<\/p>\n Nose\/Mouth\/Throat:<\/strong>\u00a0She denies runny nose, epistaxis, hoarseness, dysphagia, sinus problems, or discharge, no dental disease, and no throat pain.<\/p>\n Breast:<\/strong>\u00a0Refers to do SBE every month, denies lumps, bumps or changes.<\/p>\n Heme\/Lymph\/Endo:<\/strong>\u00a0She denies bruising or bleeding, purpura, petechiae, prolonged or excessive bleeding, no blood transfusion and HIV Hx, night sweats, swollen glands, no increase thirst, increase hunger, cold or heat intolerance.<\/p>\n Cardiovascular:<\/strong>\u00a0She denies palpitations, orthopnea, chest pain, and no edema.<\/p>\n Respiratory:\u00a0<\/strong>She denies cough, wheezing, and dyspnea at this moment.<\/p>\n Gastrointestinal:<\/strong>\u00a0She denies nausea, vomiting, diarrhea, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools, and no abdominal pain. Denies colonoscopy.<\/p>\n Genitourinary\/Gynecological:<\/strong>\u00a0She complains of creamy greenish vaginal discharge accompanied with dyspareunia, and vulvar burning, especially when she urinates, sharp pain in the lower abdomen which she rates a 3 out of 10, 4 days ago. The menarche was at 12 y\/o, the LMP: 10\/5\/2020 for 6 days, regular cycle, plus the spots already described, G1T1P0A0L1. Last Pap smear at 2020 was negative.<\/p>\n Musculoskeletal<\/strong>: She denies any limitation in movements in upper or lower extremities. No other joint pain, stiffness, swelling, or muscle plain.<\/p>\n Neurological:<\/strong>\u00a0She denies seizures, transient paralysis, weakness, black out spells, and no syncope. She refers paresthesia in bilateral lower extremities.<\/p>\n Psychiatric:<\/strong>\u00a0She denies any changes of behavior, depression, sleeping difficulties, suicidal ideation\/attempts. She refers mild distress related to painful sexual intercourse.<\/p>\n Objective:<\/strong><\/p>\n Physical Exam:<\/strong><\/p>\n GENERAL:\u00a0<\/strong>Patient is obese, no acute distress, maintain adequate hygiene. Patient is alert and oriented and answers questions appropriately. She is very cooperative and maintain good eyes contact.<\/p>\n Vital signs:<\/strong><\/p>\n Temperature:<\/strong>\u00a097.5 F<\/p>\n RR:<\/strong>\u00a018 x min<\/p>\n HR:<\/strong>\u00a073 x min<\/p>\n O2Sat:<\/strong>\u00a098 %;\u00a0<\/p>\n Blood Pressure:<\/strong>\u00a0130\/75 mmhg<\/p>\n BMI:<\/strong>\u00a032.9<\/p>\n Weight:<\/strong>\u00a0180 pounds. Height: 5.2\u201d.<\/p>\n Pain scale:<\/strong>\u00a03\/10.<\/p>\n Skin:<\/strong>\u00a0The skin is white, warm, dry, clean, pink, and intact. No noted rashes, no open wounds. Noted a mole 1\/3 superior of left side of the back, light brown, irregular shape, flat, 7 inches, not painful, not itching, no changes in color.<\/p>\n HEENT<\/strong><\/p>\n Head:<\/strong>\u00a0Normocephalic, no deformities and midline.\u00a0\u00a0Hair is clean, thick, soft, and curly and well distributed on the head. Scalp is clean, dry, and without lesions.\u00a0<\/p>\n Eyes:<\/strong>\u00a0\u00a0Symmetrical, pupils\u2019 equal round and reactive to light and accommodation, red reflex noted and light reflected symmetrically bilaterally, visual field full by accommodation. No conjunctival or scleral injection. She wears corrective lenses.<\/p>\n Ears:<\/strong>\u00a0TM is pearly gray and translucent, bony landmarks, and light reflex noted bilaterally. Canals patent. No lesion noted.<\/p>\n Nose:<\/strong>\u00a0External nose is smooth and symmetrical, firm\/stable structure noted, mucosa\/turbinates deep pink, moist, glistening. No septal deviation.<\/p>\n Throat:<\/strong>\u00a0Posterior pharyngeal wall is moist, glistening, non\/reddened, without exudate, Tonsils are 1+, bilaterally.<\/p>\n Neck:<\/strong>\u00a0Symmetric. Noted Full ROM, no cervical lymphadenopathy, no occipital nodes. No thyromegaly or nodules.\u00a0<\/p>\n Oral mucosa:<\/strong>\u00a0\u00a0Pink and moist. Pharynx is non erythematous and without exudate. Teeth are in good repair.<\/p>\n Cardiovascular<\/strong><\/p>\n Heart:<\/strong>\u00a0Upon auscultation S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs nor murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.<\/p>\n Respiratory<\/strong><\/p>\n Chest:<\/strong>\u00a0Symmetric. Lungs are clear bilaterally anterior\/posterior, no wheezing, no rhonchi, no adventitious breath sounds.<\/p>\n Gastrointestinal:<\/strong>\u00a0Abdomen flat, no deformities; BS active in all 4 quadrants, mild diffuse lower abdominal tenderness on deep palpation. No hepatosplenomegaly.\u00a0<\/p>\n Breast:<\/strong>\u00a0No tender, no deformities, no lumps or mases noted.<\/p>\n Genitourinary:\u00a0<\/strong>Bladder is non-distended; no CVA tenderness.<\/p>\n External genitalia reveal coarse pubic hair is well distribution; skin color is consistent with general pigmentation. Noted an erythematous area in the upper third of the vulva, near the urethra. Well estrogenized. A small speculum was inserted; vaginal walls are covered by purulent exudate and bleeding. Upon detaching them from the base, an erythematous area is left. Cervix is erythematous with punctate hemorrhages (strawberry-patch cervix), also friability noted and multiparous. Scant purulent and cloudy drainage present. On bimanual exam, cervix is firm, cervical motion tenderness is also present.\u00a0\u00a0Uterus is normal size, minimally tender, antevert and positioned behind a slightly distended bladder. Rectovaginal exam reveals uterosacral nodularity and exquisite tenderness. Stool is soft, brown and heme-negative. Ovaries are nonpalpable.<\/p>\n Heme\/Lymph\/Endo:<\/strong>\u00a0Upon palpation no lymphadenopathy and organomegaly noted.<\/p>\n Musculoskeletal:<\/strong>\u00a0Symmetric, full ROM in all extremities. Extremities are warm without edema.<\/p>\n Neurological:\u00a0<\/strong>Patient is A, A, OX 4. Speech clear, maintain good tone. Posture is erect. The balance is stable and the gait is rhythmical, flowing, effortless, with freely swinging legs and with an upright body posture.\u00a0<\/p>\n Psychiatric:<\/strong>\u00a0She is alert and oriented X 4. She is dressed in a clean dress and coat. She maintains eye contact. Her speech is soft, and clear, answers questions appropriately.<\/p>\n Lab Tests<\/strong><\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0NAAT: It is positive for Chlamydia trachomatis or Neisseria gonorrhoeae:\u00a0<\/strong>Still pending the result.<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Urine culture and sensitivity:<\/strong>\u00a0Still pending the result.<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Wet mount examination of cervical discharge:<\/strong>\u00a0\u00a0Sensitive indicator of cervical inflammation, in the absence of inflammatory vaginitis. Microscopy is only 50% sensitive for detection of Trichomonas vaginalis, whereas culture is the most sensitive test. Bacterial vaginosis may be diagnosed by presence of at least 3 of the 4 Amsel criteria: 1) adherent white vaginal discharge; 2) clue cells on microscopy (vaginal epithelial cells with distinctive stippled appearance as covered by bacteria); 3) vaginal pH >4.5; 4) “whiff test” (release of fishy odor following addition of 10% potassium hydroxide solution). Result shows>10 WBCs per high-power field of vaginal fluid (leukorrhea), trichomonads, clue cells, pH: 5, fishy amine odor with application of 10% KOH.<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0HIV test:<\/strong>\u00a0Negative.\u00a0<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Rapid tests (OSOM Trichomonas, AFFIRM VPIII):<\/strong>\u00a0Fast and reliable point of care tests with sensitivity >83%, specificity >97%. Results available within 10 minutes for OSOM Trichomonas rapid test and in 45 minutes for AFFIRM VP III. Result is positive for Trichomonas vaginalis<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Gram stain of cervical discharge:<\/strong>\u00a0For diagnosis of bacterial vaginosis. Nugent score is used, which involves counting bacterial morphocytes. Possible result reveals Lactobacillus morphotype reduced or absent. Still pending the result.<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Thayer-Martin agar cervical culture:<\/strong>\u00a0For detection of N gonorrhoeae. Possible result reveals growth of pathogen. Still pending the result.<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Pregnancy test:<\/strong>\u00a0It is important to determine if patient is not pregnant to provide her the appropriate treatment, avoid the teratogenesis (Jameson et al., 2020). It was negative.<\/p>\n Special Tests:<\/strong>\u00a0None<\/p>\n Primary Diagnosis<\/strong><\/p>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0A: The primary diagnosis for the patient is:\u00a0Cervicitis (N72):<\/strong>\u00a0Cervicitis is common and often asymptomatic, but if left undiagnosed or untreated can result in pelvic inflammatory disease, which can lead to substantial long-term ill effects such as infertility and chronic pelvic pain. Implementing screening protocols for high-risk populations may reduce adverse outcomes from cervicitis. Screening for other sexually transmitted infections (STIs) should be offered concomitantly. While Neisseria gonorrhoeae and Chlamydia trachomatis are the most commonly isolated organisms, in most cases no organism is identified. Clinical suspicion is generally sufficient to justify therapy, but of the diagnostic aids, nucleic acid amplification testing remains the most sensitive and specific tool for accurately diagnosing N gonorrhoeae and C trachomatis. If the presentation suggests cervicitis, and the patient is deemed at high risk for STI, patients are empirically treated with a regimen targeting STIs. There are some risk factors to develop the disease such as women of reproductive age (15 to 29 years old), prior history of STI, inconsistent condom uses and multiple sexual relationships (Jameson et al., 2020).<\/p>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In this patient, we can find some signs and symptoms such as: her c\/o foul-smelling vaginal discharged, dysuria, dyspareunia and bleeding after coitus for the last 3 weeks without relief. Patient denied fever or previous vaginal malodorous. She is sexually active and reports multiple sexual partners, a history of negative result of Papanicolaou tests in the recent past, and recent unprotected vaginal intercourse. She claims poor pain relief with Tylenol 500 mg oral every 6 hours. Also, she denies history of sexually transmitted disease, douching and antibiotic use recently. She informs the vaginal discharge looks like creamy greenish and has foul-smelling odor. She mentions that she feels a sharp pain in the lower abdomen which she rates a 3 out of 10. She refers mild distress related to painful sexual intercourse. Also, physical examination reveals vaginal walls are covered by purulent exudate and bleeding. Upon detaching them from the base, an erythematous area is left. Cervix is erythematous with punctate hemorrhages (strawberry-patch cervix), also friability noted and multiparous. Scant purulent and cloudy purulent and cloudy drainage present.\u00a0<\/p>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0On bimanual exam, cervix is firm, cervical motion tenderness is also present.\u00a0\u00a0The patient presents some risk factors to develop the disease such as women of reproductive age (15 to 29 years old), multiple sexual relationships and inconsistent condom uses.<\/p>\n Secondary Diagnosis:<\/strong><\/p>\n Secondary Diagnosis:<\/strong><\/p>\n Differential Diagnoses<\/strong><\/p>\n PLAN:<\/strong><\/p>\n Med\/Meds:<\/strong><\/p>\n Symptomatic treatment:\u00a0<\/strong><\/p>\n Treatments:<\/strong><\/p>\n Diagnostic:<\/strong><\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0NAAT<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Urine culture and sensitivity<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Wet mount examination of cervical discharge\u00a0<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0HIV test<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Rapid tests (OSOM Trichomonas, AFFIRM VPIII<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Gram stain of cervical discharge<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Thayer-Martin agar cervical culture<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Pregnancy test<\/p>\n Procedures performed:<\/strong>\u00a0None<\/p>\n Education:<\/strong>\u00a0\u00a0Patient was instructed to:<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Promote the monogamy (or at least a reduction in the number of partners)<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Encourage the use of male condoms may help prevent spread of infection.<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Educate about the importance of completing the treatment and side effects of medication.<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Encourage follow up diagnostic test to obtain an accurate and effective treatment.<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Abstain from sex until the symptoms completely heal.\u00a0<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Advised her sexual partners to go to a clinic for evaluation as there are high chances that they are infected too.\u00a0<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Observe hygiene and sanitation to ensure that the symptoms such as irritation and swelling improve.<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Advised for external dysuria may also be alleviated by urinating with the genitals submerged in water.\u00a0<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Encourage that if these symptoms do not improve in the next week of treatment, for her to come back to the clinic for more evaluation.\u00a0<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Avoid use of fabric softeners, harsh soap, nylon or synthetic underwear.<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Encourage the importance to maintain hand hygiene, diet habits and lifestyle modification such as increase physical activity.\u00a0<\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Educate about cervical cancer screening should begin approximately 3 years after a woman begins having vaginal inter- course, but no later than 21 years of age. Screening should be done every year with conventional Pap tests or every 2 years using liquid-based Pap tests (Burns et al., 2017).\u00a0<\/p>\n Referrals:<\/strong>\u00a0None<\/p>\n Follow-up:<\/strong>\u00a0\u00a0Pt is advised to follow-up in 7 days.\u00a0\u00a0If symptoms persist or worsen call or make an appt.\u00a0\u00a0Questions were answered to patient\u2019s satisfaction.<\/p>\n <\/p>\n Peer 2<\/p>\n \u00a0<\/p>\n DEMOGRAPHIC INFORMATION<\/strong><\/p>\n Name: Mrs. M.E.<\/p>\n Age: 47-year-old<\/p>\n Race: Hispanic.<\/p>\n Insurance: Medicaid.<\/p>\n Advance directives: yes, since 04\/25\/2020.<\/p>\n Subjective Data:<\/p>\n CHIEF COMPLAIN<\/strong>: \u201cI have been having hot flashes for the past few months\u201d.<\/p>\n HISTORY OF PRESENT ILLNESS:<\/strong> Mrs. ME is 47 y\/o female, Hispanic, she states in our office today because she has been having hot flashes for the past few months. Patient reports experiencing two or three hot flashes per day. Mrs. ME also reports she is awakened from sleep, soaked by night sweats. Her symptoms began seven months ago, and over that time, they have worsened to the point where have become very bothersome. She is worried because she cannot remember the date of her las period; but she’s sure she does not see her period several months ago. Patient denies headache, fever, change in appetite or weight.<\/p>\n![](\"https:\/\/learn.blackboardcdn.com\/3800.19.0-rel.54+54663c8\/images\/ci\/ng\/default_profile_avatar.svg?ts=2020-10-27T23%3A14%3A57.039Z\"){kind=avatar}
<\/p>\n<\/h3>\n
\n
\n
\n
\n
\n
\n
\n
![\"\"](\"https:\/\/nursinghomeworkwriters.com\/wp-content\/uploads\/2019\/06\/Order-Now-e1557999141851.png\")
<\/a>\n\n","protected":false},"excerpt":{"rendered":"