NR 603 Week 5 Part 1.

NR 603 Week 5 Part 1. S CC: STI Check HPI- B.S. 29 y/o, Caucasian female who presents with vaginal irritation, itching, burning, and discharge for 3 days. Pain is described as intermittent dull/burning to vagina that is worse with urination, rates as 6/10. Nothing relieves the pain as nothing has been tried at home. Patient reports vaginal discharge that is thick and clear to yellow in color. She admits to having multiple unprotected heterosexual (vaginal sex only) encounters with 2 men within the last month. Denies history of previous STDs. Uses condoms most of the time but there have been some encounters which she did not use a condom. Currently not on any form of birth control. Patient has no significant medical or surgical history. G1P1, last PAP exam was about 2 years ago and was normal. Immunizations are up to date, but she has not received the HPV vaccine. Patient has no past medical or surgical history, no known drug allergies and does not take any home medications or OTC preparations regularly. Patient is single, employed as a customer service representative for a local company and lives in an apartment with her 6 y/o daughter. Denies smoking history, drinks alcohol socially on weekends, and denies illicit drug use. ROS: Constitutional: denies fatigue, fever, chills, and weight loss/gain. HEENT: denies nasal discharge, sneezing, or tearing. CV: denies chest pain, dizziness, or shortness of breath. Resp: denies cough, shortness of breath, or congestion. GI: +lower abdominal pain. Denies nausea or vomiting. GU: LMP 7/25/2018. First period at age 13 with regular monthly cycles about every 30 days, admits to unprotected sex with 2 sexual partners. denies dysuria, urgency, frequency, blood in urine, pain with urination, +vaginal discharge, itching, burning, and dyspareunia. MUSCULOSKELETAL: denies muscle aches or weakness. SKIN: denies lesions or rashes. NEURO: denies numbness, tingling, or dizziness. PSYCH: denies anxiety, depression, or SI/HI. ENDO: denies heat or cold intolerance. LYMPH: denies bleeding, bruising, or infection. ALLERGIC: denies any allergies. O PE: General: This is a 29 y/o female that is afebrile, with normal vital signs BP: 104/68 HR: 76 RR: 14 T: 98.1 O2: 98% RA Ht: 65 inches Wt: 132 pounds, BMI 20.53. Appears in no acute distress. She is alert and oriented x 3 with normal mood and affect. HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. No sinus tenderness. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink. No septal deviation. Neck: Supple. Full ROM. No lymphadenopathy, thyromegaly, or nodules. Oral mucosa pink and moist. Pharynx pink. Teeth are in good repair. Chest/Lungs: Chest wall symmetrical, no use of accessory muscles, breath sound clear to auscultation bilaterally in all fields. CV: S1, S2 noted with regular rate and rhythm. No clicks, rubs, or murmurs noted. Capillary refill less than 3 seconds. Pulses 3+ in all extremities. No edema noted. Abdomen: Abdomen is soft and nondistended without lesions or discoloration with normal bowel sounds present in all 4 quadrants. Tenderness noted upon palpation in right and left lower quadrant. No guarding or hepatosplenomegaly. Genital: External genitalia normal w/o lesions. Vulva erythematous, excoriated, and swollen. Vaginal mucosa pink with moderate amount of thick white discharge without odor present in vaginal canal. Cervix intact without lesions or tenderness. Uterus midline, mobile, and non tender. No adnexal masses palpable. Specimens collected via swab for GC/Chlamydia and Trichomoniasis Musculoskeletal: ROM intact in all extremities. Neurologic: Alert and oriented with normal affect and mood. Speech clear and organized; answers questions appropriately. Gait steady; able to move all extremities well. Sensations intact. Skin: Skin pink, warm, and dry with good turgor. No rashes, lesions, or ulcers. Associated Risk Factors Unprotected sex with one or more partners of unknown status is a major contributing factor of contracting an STI. In this case BS admits to having multiple unprotected sexual encounters with more than one person of unknown status. Social, economic, and behavioral factors also contribute to increased risk. Racial and ethnic disparities are among risk factors and has shown that African Americans and Hispanics have the highest STD rates. These rates are thought to be related to lack of access to care, social stigma, poverty, and substance abuse (U. S. Department of Health and Human Services [USDHHS], 2014). BS has inconsistent use of condoms and alcohol use which increases her risk of contracting an STD. Differential Diagnosis Bacterial Vaginosis (N76.0) Bacterial Vaginosis is associated with changes in vaginal pH and is the most common cause of BV. Risk factors include multiple, new sex partners, tampon use, contraceptive devices, douching, and the use of perfumed soaps and feminine hygiene products (Hollier, 2016). Typical findings include vaginal discharge that has a fishy odor. Mixed bacterial vaginitis can present as itching, dyspareunia, pale or shiny vaginal epithelium, and friability (Hollier, 2016). BS reports vaginal discharge that is white to yellow in color, itching, and multiple sex partners making BV a likely diagnosis. Clue cells are key diagnostic findings in BV. The diagnosis is made based on vaginal exam, results of vaginal swabs, vaginal pH testing, whiff test, and oligonucleotide probes test results. Diagnosis can be made based on three or more positive findings from any of the above four tests according to (CDC, 2015). The rationales for identifying bacterial vaginosis are the patient’s reported symptoms and physical findings. Unlike other STI’s such as gonorrhea and chlamydia; BV is not considered a sexually transmitted infection but is more common among sexually active women. Candidiasis (B37.3) Candidiasis is commonly known as yeast infection. The infection is caused by fungus candida, which causes vulvovaginal itching, burning, irritation, and thick white discharge that is often described as “cottage cheese” like in appearance and is usually odorless. Vaginal candidiasis cannot be ruled out as a possible diagnosis because the patient does complain of itching, vaginal discharge, and irritation (CDC, 2016). Pelvic Inflammatory Disease (N73.9) Pelvic inflammatory disease (PID) can be caused by various bacteria and/or microorganisms that affect the vagina, cervix, uterus, ovaries, fallopian tubes, and endometrium. These bacteria are predominately transmitted via sexual contact. The most common sexually transmitted infections that lead to PID are untreated Chlamydia trachomatis and Neisseria gonorrhea. These bacteria travel on the mucosal lining of the vagina into the lower abdominal cavity leading to pain and inflammation (Black, 2014). Most women may present with no symptoms, but when they do occur they are generally localized to the lower genitourinary tract and include vaginal discharge, abnormal bleeding, urinary frequency or dysuria, fever, dyspareunia, cervical motion tenderness on exam, and rectal discomfort. The vulva, vagina, cervix, and urethra may be inflamed and may itch or burn. BS reports lower abdominal/pelvic pain, vaginal discharge, and dyspareunia which can be symptoms of Pelvic Inflammatory Disease (PID). BS has multiple risk factors such as unprotected sex with multiple contacts, inconsistent use of barrier methods, and alcohol use which increases the chances of contracting an STI. Diagnosis is based on symptoms and physical exam. There is no diagnostic test to confirm PID. It is based on the history and physical obtained by the provider. A detailed sexual history and clinical findings are the key components to accurate diagnosis. Any woman presenting with symptoms of vaginal discharge should be evaluated with a physical examination, wet mount and potassium hydroxide preparation to determine the cause of the discharge so appropriate treatment can be initiated (Sabb et al., 2018). Compare/Contrast Differentiating S/Sx Differentiating Dx Criteria/Testing BV Thin vaginal discharge with a fishy odor. Gram stain is considered the gold standard of diagnosis. Clue cells on microscopic exam and vaginal pH 4.5. KOH whiff test will be positive (fishy odor). Candidiasis Thick white vaginal discharge associated with external itching and burning of genital area. KOH prep will likely show hyphae or budding yeast on microscopic examination. PID Since most infections are polymicrobial either caused by gonorrhea and chlamydia infections making the diagnosis a challenge for providers. Multiple infections can invade the female reproductive tract causing abdominal pain, fever, dyspareunia, and abnormal bleeding. There are no differentiating tests. PID is a clinical diagnosis; but cervical, uterine, or adnexal tenderness are key findings in diagnosing PID especially in presumed chlamydia or gonorrhea infections (CDC, 2015). Labs: Urinalysis, Urine HCG, Urine C&S pending, GC/Chlamydia pending. CDC recommends diagnosis and evaluation to include physical exam noting any mucoid, mucopurulent, or purulent discharge, pelvic pain, cervical motion tenderness, or other signs of infection. If point-of-care testing is not available, nucleic acid amplification tests (NAATs) should be performed, and the patient should be treated empirically for gonorrhea and chlamydia. In women, NAATs can be performed on vaginal, endocervical, and urine specimens and is 3-5 times more sensitive in detecting infection compared to wet-mount microscopy (Hauk, 2016). Because of high incidence of reinfection, the CDC recommends repeat testing 3 months after treatment in those with confirmed diagnosis of chlamydia or gonorrhea regardless of partner status or treatment (Hauk, 2016). Reference Black, A. (2014). Management of pelvic inflammatory disease. Nurse Prescribing, 12(9), 443- 450. Retrieved from Centers for Disease Control and Prevention. (2015). Bacterial Vaginosis. Retrieved from Centers for Disease Control and Prevention. (2016). Genital/vulvovaginal candidiasis. Retrieved from external site.) Centers for Disease Control and Prevention [CDC]. (2015, June 04). Pelvic Inflammatory Disease (PID). Retrieved from Hauk, L. (2016). CDC Releases 2015 Guidelines on the Treatment of Sexually Transmitted Disease. American Family Physician, 93(2), 144. Hollier, A. (2016). Clinical guidelines in primary care (2nd ed.). Scott, LA.: Advanced Practice Education Associates. Sabb Gul, B. K., Albati, Z. A., Ismaeel Badr, R. R., Alfaraj, Z. M., Almatrafi, A. S., Banoun, A. A., & ... AlJuhani, A. S. (2018). Pelvic Inflammatory Disease. Egyptian Journal Of Hospital Medicine, 70(9), . doi:10.12816/ U. S. Department of Health and Human Services [USDHHS]. (2014). Sexually Transmitted Diseases. In Healthy People 2020. Retrieved from diseases U.S. Preventative Services Task Force [USPSTF]. (2016). Final Recommendation Statement: Chlamydia and Gonorrhea: Screening - US Preventive Services Task Force. Retrieved from ntFinal/chlamydia-and-gonorrhea-screening#Pod5 ASSESSMENT: Lab Test and Results: Labs: Urine dipstick: 1+ bacteria, negative nitrites, negative leukocyte esterase, and no blood or ketones present. Urinary tract infection can be ruled out. Urine culture showed no growth. Urine HCG: Negative. Pregnancy should be ruled out initially because treatment will vary based on a positive or negative result. Point of care testing was not available so samples were sent out for nucleic acid amplification tests (NAATs). In women, NAATs can be performed on vaginal, endocervical, and urine specimens and is 3-5 times more sensitive in detecting infection compared to wet-mount microscopy (Hauk, 2016). GC /Chlamydia negative. CDC recommends diagnosis and evaluation to include physical exam noting any mucoid, mucopurulent, or purulent discharge, pelvic pain, cervical motion tenderness, or other signs of infection. If point-of-care testing is not available, should be performed, and the patient should be treated empirically for gonorrhea and chlamydia. Because of high incidence of reinfection, the CDC recommends repeat testing 3 months after treatment in those with confirmed diagnosis of chlamydia or gonorrhea regardless of partner status or treatment (Hauk, 2016). The American Congress of Obstetricians and Gynecologists recommends screening for chlamydia and gonorrhea in sexually active females aged 25 years or younger37. It also recommends screening for chlamydia in women older than 25 years who have risk factors (such as new or multiple sex partners) and for gonorrhea in asymptomatic women who are at high risk for infection (such as those with a previous gonococcal infection, other STIs, or new or multiple sex partners, as well as inconsistent condom use, commercial sex work, or illicit drug use).(U.S. Preventative Services Task Force [USPSTF], 2016). O Physical Exam: V/S: height 64 inches, weight 124 lbs., B/P 118/67, HR 89, RR 16, T 98.2, SpO2 99%, Pain 6/10. Awake, alert, and oriented female appears in no acute distress. Cooperative and can answer questions appropriately in complete sentences when prompted. HEENT: Head is normocephalic, EOMs intact, PERRL, sclera clear, no conjunctival injection or drainage. TM’s grey, intact bilaterally, no bulging or erythema, + light reflex. No tragal tenderness. Nares patent, no nasal drainage or congestion. Oral mucosa pink and moist. No erythema, tonsillar enlargement, exudate or swelling noted. Airway patent. Good dentition. Neck: Supple without lymphadenopathy, thyroid midline. ROM intact. Cardiovascular: Normal rate and rhythm, S1 S2 present. No murmurs or rubs. No JVD. No cyanosis, clubbing, or edema. 2+ pulses bilaterally at the carotid artery. 3+ pulses bilaterally at radial, DP, and PT arteries. Lungs: Chest wall symmetric, respirations even and unlabored. Lungs CTA bilaterally. Abdomen: Rounded and firm with bowel sounds present in all quads, no organomegaly noted, +tenderness to palpation in suprapubic area. Genitourinary: Vaginal exam unremarkable. Labia majora and minora intact without lesion. No Bartholin or Skene gland swelling noted. Vagina is purplish, moist with no lesions or abnormal drainage. +Chadwick’s sign noted to cervix. Enlarged uterus noted with approx. 22cm fundal height. Gyn: LMP approx. 12/25/17. Obstetric History: G0, P0. Neurological: Cranial nerves intact, able to follow commands, no focal deficits noted. Awake, alert, and oriented to person, place, and time. DTRs 2/5 throughout. MAE. Full active ROM. Psychiatric: Able to answer questions appropriately. No anxiety or depression noted. Derm: Skin warm and dry, normal in color with good turgor, no rashes, lesions, bruises, or wounds. Musculoskeletal: Muscle strength and tone appropriate for age and symmetrical. No crepitus, swelling, tenderness and deformities. ROM intact in all extremities. Urinalysis in the office: Yellow urine, Sp. Gr. 1.010, positive WBCs, but no nitrites or leukoesterase; negative for RBCs, glucose, and ketones Trichamoniasis, Chlamydia and Gonorrhea vaginal cultures sent. STD Lab Results Patient: Kayla Smith Acc #: 12345 Patient #: KS Birth: 6/18/1987 Collection Date: 11/04/2013 Doctor: NON-STAFF Age: 26 years Received in Lab: 11/04/2013 Home Phone: Gender: Female DR SMITH Test Name Result Flag Reference Interval Lab Chlamydia/GC Amplification Chlamydia trachomatis, NAA Positive Abnormal Neisseria gonorrheae, NAA Negative Urine Pregnancy Test—Negative A. Primary Diagnosis: Vulvovaginal candidiasis (Z33.1) – Urine pregnancy test is positive. (Fenstermacher & Hudson, 2016) Kayla’s urine pregnancy test was positive. B37.3