Clinical Case Presentation - A. Raley

Information about Clinical Case Presentation - A. Raley

Published on July 30, 2014

Author: ashleyraleyrn

Source: authorstream.com

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Clinical case presentation: Clinical case presentation BY: ASHLEY RALEY NURS 630 MARYVILLE UNIVERSITY Chief complaint: Chief complaint The patient was a 21 year-old Caucasian female who was 24 weeks pregnant and presented to the clinic with the following complaints that started one week ago: Increased vaginal discharge Notable foul vaginal odor Vaginal itching Hpi: Hpi The patient reported she first noted foul vaginal odor, described as a “fishy” smell one week ago. At this time, she also noticed a change in vaginal discharge that she described as a moderate amount of thin, yellowish-white discharge which has persisted over the past week. Recently, she had also experienced increased vaginal itching. She reported she started wearing panty-liners to keep area as dry as possible and help with vaginal irritation. She denied any change in sexual partners. She denied signs or symptoms of abdominal cramping, pelvic and vaginal pain since the onset of symptoms. She reported she has maintained good perineal hygiene. She denies douching. Ros: Ros Constitutional : Repots feeling well and denies fever, chills, or malaise . ENT : Denied nasal congestion/discharge , sore throat, hoarseness, ear pain, or nose bleeds. Cardiovascular: Denies chest pain, heart palpitations , syncope, or peripheral edema . Respiratory: Denies shortness of breath, wheezing, or cough. Gastrointestinal: Denies abdominal pain or cramping. Denies nausea , vomiting, or diarrhea. Genitourinary: Denies urinary hesitancy , dysuria , or hematuria . GYN : Vaginal complaint of increased yellow/white vaginal discharge, itching, and "fishy" odor. Denies vaginal bleeding. Reports good fetal movement. Neurological : CN 2-12 grossly intact Psychiatric: Denies anxiety, depression. Hematologic: Denies easy bleeding and bruising. Lymphatic: Denies lymph node enlargement Past medical & Surgical history: Past medical & Surgical history Medical History: No significant medical history G1P0A0 Denies history of STIs Surgical History Tonsillectomy with adenoidectomy - 1997 Allergies/medications: Allergies/medications Allergies No known food or drug allergies Current Medications Prenatal Multivitamin 1 tablet PO daily Family & social history: Family & social history Family History Maternal history of hypothyroidism Siblings – younger brother and sister without significant medical history Father – history of hypertension and hyperlipidemia Social History Denies history or current use of tobacco, alcohol, or recreational drugs Engaged Involved in long-term relationship since high-school Reports history of 2 sexual partners. Denies multiple sex partners. Patient currently enrolled in online program at LSU and works part-time for veterinarian office completing secretarial work. Physical exam data: Physical exam data Vitals Blood pressure: 110/70 left arm; 112/70 right arm Pulse: 82 bpm Respirations: 16 breaths/minute Temperature: 97.9 O 2 Saturation: 99% RA Pain 0/ 10 Height: 5’5 Weight 135lbs BMI: 22.5 Physical exam data: Physical exam data Constitutional: healthy, well-nourished , 24-week pregnant, Caucasian female in no apparent Skin : pink, warm, no rash or lesions present, good skin turgor Eyes: PERRLA, extra ocular muscles intact, sclera white, bilateral conjunctiva are pink ENT: Bilateral TMs translucent. T urbinates pink and moist. No nasal congestion. Good dentition, gingiva pink. Oropharynx pink, no post -nasal drainage, or erythema noted. Tonsils 1+ . Uvula midline, gag reflex intact. Neck: trachea is midline , full neck ROM , no enlargement of thyroid, bilateral carotid pulses +2 and negative for bruit and thrill Cardiovascular: Regular rate and rhythm, - S1/S2 heard upon auscultation, no ectopy , murmurs, or rubs. Carotid pulses and S1 synchronous . Peripheral pulses +2. Cap refill less than 2 seconds. No peripheral edema. Pulmonary: Lungs clear to auscultation. Respiratory rate 16 breaths per minute. No labored breathing or accessory muscle use. No cough. Chest expansion symmetric with inspiration. Abdomen: Fetal height 25cm. Fetal heart tones - 147. No abdominal pulsations or bruits, bowel sounds active in all four quadrants. GYN : Pelvic exam completed with use of speculum insertion to assess vaginal canal and cervix. A moderate amount of thin yellow vaginal discharge was present in the vaginal canal. KOH Whiff test completed – positive. Small sample collected for pH testing and for microscopy exam.  Positive clue cells on saline mount when visualized under microscope. Vaginal pH increased at 5.0. Normal vaginal pH range is 3.8-4.5. Lymphatic : No lymphadenopathy noted. Neurologic : Alert and oriented x 3. CN 2-12 grossly intact. Motor strength normal to upper and lower extremities. Deep tendon reflexes intact. Sensory intact Psychiatric : calm and pleasant affect. Differential diagnoses: Differential diagnoses (Lumera Health, 2014) Amsel criteria: Amsel criteria Diagnosis – Bacterial vaginosis 1 . Presence of thin , white discharge that coats the vaginal walls. 2. Vaginal pH greater than 4.5 3. Positive KOH Whiff Test 4 . Presence of clue cells on microscopic exam (CDC, 2010) Microscopic findings: Microscopic findings (UpToDate, 2014) Assessment and plan: Assessment and plan Metronidazole 500mg BID x 7 days. Treatment of partner is not indicated. Practice safe sex. Do not douche during pregnancy as it is not recommended and will also alter pH of normal vaginal flora Patient informed that BV is quite common in pregnancy Explained importance of treating symptoms and taking full course of medication even if symptoms resolve. Pregnant women with BV are at higher risk for preterm delivery Patient instructed to wear cotton underwear and change more frequently to keep vaginal area from developing too much moisture, i.e. sweating or after exercise Patient may take Probiotic for treatment and prevention of future bacterial vaginosis. References: References Center for Disease Control & Prevention. (2010). Diseases characterized by vaginal discharge. Retrieved from http:// www.cdc.gov/std/treatment/2010/vaginal -discharge.htm Lumera Health. (2014). Vaginitis: clearing up the confusion. Retrieved from http://www.gynazole-1.com/pts_YI_Similar_ to_Other_Infections.aspx UpToDate. (2014). Bacterial vaginosis. Retrieved from http ://www.uptodate.com.proxy.library. maryville.edu/contents/bacterial-vaginosis? source=machineLearning&search=bacterial +vaginosis&selectedTitle=1~87&section Rank=1&anchor=H8#H8

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