Juliana A Mirabelles Case Study Help

1. Juliana Mirabelles Ihuman Case Study By i-humancasestudyanswers.com CC: Pain with urination is the presenting problem

2. Reason for encounter: “I have been having burning when I pee. I was worried that I had another bladder infection, but these symptoms are a little different than the symptoms I had with my last UTI” Hisotry of present illness- The patient is a 25-year-old heterosexual female. She presents to the office with c/o dysuria, burning during urination, and vaginal discharge. Her symptoms began three days ago. She is unsure of the events surrounding the start of these issues. Her vaginal discharge can be characterized as yellow, kind of mucousy, kind of creamy, not too smelly. She reports that her urine appears normal without hematuria. She reports that soaking in a warm bath helps alleviate her dysuria but states that nothing appears to alleviate the vaginal discharge. She has attempted no treatments for these symptoms. The severity of her dysuria discourages her from wanting to urinate. She also reports that her dysuria is worse at the start of urination. Genital pain 4/10 hurts when she pees feels like burning, superficial pain Spotting during intercourse OTC meds- take ibuprofen with period for cramps and headaches Currently sexually active HPI: patient presents to the clinic with ROS: General: denies weight loss, malaise, or night sweats. pt. reports dysuria,burning during urination, and vaginal discharge.Patient is a good historian for her health hx HEENT/ Neck : head: negative eyes: negative ears: negative Nose: negative throat: negative neck: negative Cardiovascular: denies chest pain Respiratory: negative Gastrointestinal: negative Genitourinary: Genital pain 4/10 hurts when she pees and feels like burning, superficial pain. dysuria, burning during urination, and vaginal discharge- "yellow, kind of mucousy, kind of creamy, not too smelly". denies vaginal itching; denies hematuria

3. Musculoskeletal/ Osteopathic structural examination: negative Neurologic :negative Integumentary/ breast: negative Psychiatric: negative Endocrine: negative Hematologic/ lymphatic : negative Allergic/ immunologic : negative Past medical hx: Hospitalizations/ surgery: Preventative health : No previous HPV vaccination. General immunization status: the patient thinks she is up to date. Medications: takes ibuprofen with her menstrual period for cramps and headaches. the patient is still taking her oral contraceptive pill Allergies: NKDA Social hx: Denies pain with sex but hasn’t had sex since this all started Pt. denies using any form of STD protection. Pt has more than 1 sexual partner Denies hx of STDs Family hx: Physical exam: General: the patient is AxOx4. She appears well-groomed and appropriately dressed. Her speech is clear and follows a logical sequence. She does not appear to be in any distress; her skin is pink, warm, and intact. HEENT/Neck: Head normocephalic, atraumatic. Scalp and temporal arteries are non-tender. Eyes: PERRLA, EOMI. No ptosis or periorbital edema present Throat: oropharynx not injected, clear mucosa, tonsils without exudate Neck: no decreased ROM

4. Cardiovascular: normal heart rate with normal rhythm. No heaves, thrills, or bruits. PMI location at the 5th intercostal space mid-clavicular line Chest/ respiratory: clear to auscultation b/l. no wheezing or rales Abdomen: soft non-tender, normo-active bowel sounds. No hepatomegaly or splenomegaly. GU/rectal: mucopurulent discharge issuing from the cervical os, cervix appears friable , vaginal ph 4.0 Musculoskeletal/ Osteopathic structural examination: normal muscle bulk and tone throughout Neurologic : cranial nerves 2-12 are intact Skin: pink, warm, and slightly moist without lesions Lymphatic: Psychiatric: Assessment/ plan: or soap note below assessment: pharmacologic management: non- pharmacologic management: patient education: follow up: Problem statement: J.M is a 25 y/o female with a hx of UTIs. She presents with c/o of dysuria, burning upon urination, genital pain and vaginal discharge that began 3 days ago. She reports having multiple sexual partners; she does not use protection against STDs. Her physical exam reveals mucopurulent discharge from the cervical os and a friable cervix. assessment: cervicitis: culture-proven, uncomplicated gonorrhea pharmacologic management: cefriaxone 250mg administered (IM) single-dose AND azithromycin 100mg PO Bid for 7 days patient education:

5. Please contact the office if pain worsens or pelvic pain begins. If the office cannot be reached please go to the nearest emergency room. Use a backup method of birth control. follow up: follow up with the office in one week. Please follow up sooner if symptoms worsen. Encourage the patient to avoid sexual intercourse until symptoms resolve and to practice safe sex measures such as using a condom Powered by TCPDF (www.tcpdf.org)