FSU Patient Case With Vaginal Discharge Discussion

Please respond to discussion below using current APA edition and 2 scholarly references. Must be at least 150 words.

My second week of clinical rotations was good. I felt more comfortable in charting and engaging in different patient cases with my preceptor. I managed to see many patients this week inpatient and outpatient in group homes. I saw a lot of patients with a variety of illnesses ranging from young adults to older adults with intellectual disabilities, obesity, sexually transmitted infections, hypertension, etc. My preceptor is fast paced but she is also thorough and answers all of my questions unbothered, which is great because I know other practitioners who may show that they are aggravated.

Chief of Complaint and HPI

One of the patient’s that I have seen this week was Ms. A.V, a 40-year-old Hispanic female who presents in the office for annual physical and complaints of abnormal vaginal discharge with itching. The patient has a history of recurrent vaginal yeast infections, vertigo, ovarian cyst, constipation, and overweight. The Patient complains of vaginal Itching, yellow/greenish discharge for past two months, painful intercourse. Patient denied abdominal pain. The reported seeing a gynecologist a week prior, after a vaginal culture was done, she was prescribed doxycycline 100mg BID for 7 days, fluconazole, Clindeese 2% cream, and probiotics. Patient reported this is the 3rd infection within the past two months. Patient is sexually active.

Assessment

The patient observed AAOx3, well dressed, functional ADLs. Patient observed frustrated. Vital signs BP 110/80, Pulse 88, T 98.9F, R 17, O2 Sat 98%, BMI 30. Upon physical examination, scant yellow discharge observed in vaginal area with redness and no lesions, abdomen is obese, soft, non-tender to touch, no masses noted, the rest of the physical examination was unremarkable.

Plan of care

• Continue taking the prescribed medications as directed.
• Refer to gynecologist.
• Avoid douching.
• Cervical cancer screening
• Refer to endocrinologist.
• Pelvic ultrasound ordered.
• Order labs for estrogen levels: pre-menopausal/post-menopausal women with low estrogen levels causes a lack of presence of lactobacilli in the vagina and an elevated vaginal pH that is > 4.5.
• For weight loss: Recommended exercise 30 minutes day 5 x week, recommended that patient maintain a healthy BMI of 18-25 by cutting out fatty foods and sugary beverages, will continue to monitor weight and follow up next visit.
• Encourage patients to eat yogurts for probiotics to promote healthy normal flora.

Differential Diagnoses

Three possible differential diagnoses for the abnormal vaginal discharge include gonorrhea, trichomoniasis, vaginitis. the client presents with abnormal (yellow/green) discharge, she reports it having a bad smell, she reports itching, and pain with intercourse; Vaginitis has symptoms of abnormal vaginal discharge, odor, itching, spotting, dysuria, spotting, and discomfort (Sobel, 2023). Trichomoniasis also has clinical manifestations of greenish-yellow discharge, burning sensation, pruritus, dysuria, urinary frequency, or dyspareunia. Each of these diagnoses can be confirmed or ruled out with lab tests such as the NAAT tests, PH testing, and microscopy (American College of Obstetricians and Gynecologists, 2020). Gonorrhea includes manifestations of sore throat, vaginal discharge, dysuria, heavy menses, painful intercourse, sore throat, fever, and lower abdominal pain; the client has most of symptoms except fever, heavy menses, sore throat, and lower abdominal pain.

Health Promotion Interventions

Heath promotion interventions for this patient includes cervical cancer screening (pap smear), continue taking antimicrobial medications as directed by gynecologist, avoid douching, avoid wearing nylon underwear, regular STD screening tests with partner. Drink plenty of fluids (at least 1,500ml-2,000ml/day). Integrate healthy food into diet, cutting out fatty foods and sugary beverages. Encourage patients to eat yogurts for probiotics to promote healthy normal flora. Utilize stress management techniques.

This week I learned how to have more hands-on experience; I was able to conduct physical examinations for the first time with my preceptor observing me. Having more hands-on experience allowed me to feel more confident and at ease gaining skills and knowledge for documenting my patients’ subjective, objective findings, implementing adequate plans of care, and coding for their diagnosis’s. I also learned how to send referrals to other practitioners for consultations.