GYNECOLOGICAL HEALTH

GYNECOLOGICAL HEALTH 

Pt is a   30y/o AA female, who is a new patient that has recently moved to Miami and she is concerned about her gynecological health. She seeks treatment today after   unsuccessful self-treatment of vaginal itching, burning upon urination, and   lower abdominal pain. She is concerned   for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with   urination has been present for 3 weeks, and the abdominal pain has been   intermittent since months ago. Pt has   tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms,   including urgency or frequency. She   describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10   at times. 200mg of PO Advil PRN   reduces the pain to a 7/10. Pt denies   any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but   denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any   vaginal irritants. She reports that   she is in a stable sexual relationship, and denies any new sexual partners in   the last 90 days. She denies any   recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well   as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also   takes Advil for. She reports her last   PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP   smear result. Pt denies any hx of   pregnancies. Other medical hx includes   GERD. She reports that she has an Rx   for Protonix, but she does not take it every day. Her family hx includes the presence of DM   and HTN.

Gastrointestinal

Abdomen   flat; BS active in all 4 quadrants. Abdomen soft, suprapubic   tender. No hepatosplenomegaly.

Genitourinary

Suprapubic   tenderness noted. Skin color normal   for ethnicity. Irritation noted at   labia majora, minora, and perineum. No ulcerated lesions noted. Lymph nodes   not palpable. Vagina pink and moist   without lesions. Discharge minimal,   thick, dark red, no odor. Cervix pink   without lesions. No CMT. Uterus normal size, shape, and consistency.

Musculoskeletal

Full   ROM seen in all 4 extremities as patient moved about the exam room.

Urinalysis   – blood noted (pt. on menstrual period), but results negative for infection

Urine   culture testing unavailable

Wet   prep – inconclusive

STD   testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B   & C

Diagnosis

o Urinary   tract infection, site not specified. (N39.0) Candidiasis of vulva and vagina.   (B37.3) secondary to presenting symptoms (Colgan & Williams, 2011) & (Hainer   & Gibson, 2011).

    • Medication –
  • Terconazole cream 1 vaginal application QHS for 7 days for   Vulvovaginal Candidiasis;
  • Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days   for UTI (Woo & Wynne, 2012)
  • Education –
  • Medications prescribed.
  • UTI and Candidiasis symptoms, causes, risks, treatment,   prevention. Reasons to seek emergent care, including N/V, fever, or back   pain.
  • STD risks and preventions.
  • Ulcer prevention, including taking Protonix as prescribed,   not exceeding the recommended dose limit of NSAIDs, and not taking NSAIDs on   an empty stomach.
  • Follow-up         
  • Pt will be contacted with results of STD studies on GYNECOLOGICAL HEALTH
  • Return to clinic when finished the period for perform   pap-smear or if symptoms do not resolve with prescribed TX.