Health

PATIENT INFORMATION:

NAME: A.R.

SEX: Female.

AGE: 28 y/o

ALLERGIES: Latex.

IMMUNIZATION STATUS: Up to date

PREVIOUS SCREENING TESTS RESULT: Negative Pap incrust in 09/26/2019, no fact of unnatural pap results.

PRIOR HOSPITALIZATIONS: No hospitalizations.

CURRENT MEDICATIONS: none.

PAST MEDICAL HISTORY: Unremarkable

OB AND GYN HISTORY:

Menarche: 11 years old

Lent of cycle: 28 days/4-5 days, recurrent.

L.M.P: 08/20/2020 typical bleeding.

Pregnancy fact: G1, T0, P0, A1 (willing puck 20017), L0

History of STIs: None

No fact of unnatural pap result

Sexual fact: erratic, applys barely one coadjutor now. Heterosexual.

Contraceptive use: norethindrone-ethinyl estradiol, one pill ample day

SURGICAL HISTORY: ordinary.

GYN PROBLEMS/PROCEDURES: None

FAMHX: Mother quick (Migraine).

SOCIAL HISTORY: The resigned was born in Cuba, never married, elaborate and started now, she’s not smoker, no used alcohol or illicit drugs. Refers she drain coffee 2-3 periods per day.

SUBJECTIVE:

CC: “I’m having yellow vaginal perform and cogent effluviumy”.

HPI: A 28-year, womanly, Hispanic family, follow to our medical station reporting she having three days behind a occasion yellow vaginal perform behind a occasion a cogent effluvium, accompanied bit disinclination in the inferior abdomen, and she applys used laagered sex in the definite month divergent periods behind a occasion her new boyfriend, she denies having heat, end disinclination, urinary symptoms, denies disgust, no vomiting, no unnatural vaginal bleeding among eras. Her definite late menstrual era was 3 weeks ago. Denies any late medical stipulation.

ROS:

CONSTITUTIONAL: Resigned denies chills, heat, moment privation, diminished proclivity, uncommon thirsty, but has had sudden generalized faintness for the definite month.

HEENT: Eyes- Denies diplopia, eye disinclination, blurred expectation, redness, or shining slights. No use regulative lenses or glasses. Ears, nose, opening, and throat- Resigned denies vertigo, headaches, sinus problems, epistaxis, hoarseness, dental problems, unwritten lesions, hearing privation or changes, nasal redundancy.

CARDIOVASCULAR: Denies chest disinclination, palpitations, dizziness or jade.

RESPIRATORY: Denies deficiency of life, denies cough, redundancy or formation of

sputum

GASTROINTESTINAL: Denies abdominal disinclination, no fact of abdominal surgery, also

denies rectal bleeding and constipation, no diarrhea.

GENITOURINARY: Denies steady surprise, no quantity urination. No end disinclination, no nocturia. No medical fact stipulations.

GYNECOLOGICAL: No vaginal bleeding. no intermenstrual bleeding, or postictal bleeding, applys having three days behind a occasion yellow vaginal perform behind a occasion a cogent effluvium, accompanied bit disinclination in the inferior abdomen, and she applys used laagered sex in the definite month divergent periods behind a occasion her new boyfriend disinclination behind a occasion connection (dyspareunia). Denies medical fact of STD.

MUSCULOSKELETAL: Denies muscle faintness or spasms, muscle or flexure disinclination.

SKIN: Denies fresh venturesome or sudden onslaught of bark lesions.

NEUROLOGIC: Denies tremors, headache, seizures, smooth trice imbalance due to leg disinclination tics or insensibility in inferior extremities, no visual disturbances or address problems, no dizziness.

OBJECTIVE:

PHYSICAL EXAMINATION:

GENERAL: Healthy-appearing, well-nourished, and well-developed. Alert in no harass, and cooperative. Typical trice, no criticize privation or construct.

Vital Signs:

BMI: 24.5 kg/m2

Blood Pressure 110/72 mm hg

Pulse: 90 P/min,

Respiration rate:18 lifes /min.

Weight:152 pns.

Height: 5'6''

Temperature 97.9 oF.

SpO2: 98 % on locality air.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Eyes: Sclera bite,

conjunctiva pink, no icterus, immoderate break, or exudate, no edema or lesions illustrious. PERRLA. Visual acuity and extraocular eye movements sacred. Ears: Bilateral canals evident and non-tender, but behind a occasion remarkable erythema. No edema, lesion, or exudate. Bilateral tympanic membranes sacred, pearly silvery behind a occasion ardent cone of slight. Throat: Posterior oropharynx typical; uvula midline. Mucous membranes pink, lively, behind a occasionout ulceration.

CARDIOVASCULAR: No jugular venous distention, reexoteric core rate and rhythm behind a occasionout whispers, rubs, or gallops, there is no chest deference benevolence on unchanged interest, no parallel prevalence, no carotid whisper bilaterally.

RESPIRATORY: The resigned is symbolical in ample sentences, no dyspnea or use of friend muscle, no indiscriminateness to encounter, or increased tactile fremitus aggravate the lung fields has no cyanosis, rhonchi or crackles illustrious, vesicular whisper bestow bilaterally.

GASTROINTESTINAL: Unwritten smoothness behind a occasion no lesions postulatory of poison, wet unwritten mucosa, abdomen smooth, non-tender, non-distended, no abdominal scars, no organomegaly, no hernias, bowel sounds bestow in all lewd quadrants

GENITOURINARY: Encounter aggravate CVA elicits no disinclination.

GYNECOLOGICAL: Speculum examination: typical classification and quantity of pubic hair, no superficial genitalia lesions, no ulcerations, yellow mucoid cervical perform; crisp aspect of the cervix; and cervical agitation benevolence.

MUSCULOSKELETAL: Denies muscle faintness or spasms, muscle or flexure disinclination.

INTEGUMENTARY: Pink, fiery, no venturesome, no nevi reported as noxious, no macules, papules or vesicles, no other bark faintness.

NEUROLOGIC: AAOx3, no trice disturbances, no convenient or peripheral focal neurological deficit, muscle loudness, retain force and shameful surprise, sacred.

ASSESSMENT:

Chlamydial Taint of Genitourinary Tract, Unspecified (ICD10 A56.2): Could be asymptomatic or be bestow behind a occasion Unnatural vaginal perform that may enjoy an scent, bleeding among eras, Painful eras, dyspareunia, Hankering or steady environing the vagina, disinclination when urinating. Motive pelvic exasperating disorder, Cervicitis, endometritis, salpingitis (Black, 2013). This resigned follow to the medical station behind three days behind a occasion yellow vaginal perform behind a occasion a cogent effluvium, accompanied bit disinclination in the inferior abdomen, and apply laagered sex in the definite month.

Other Diagnosis:

ICD 10: Z72.51; High endanger heterosexual action.

Differential Diagnosis:

Gonococcal vulvovaginitis, unspecified (ICD10 A54.02): Perform from the vagina (watery, creamy, or partially inexperienced). Disinclination or steady surprise occasion urinating. Motive pelvic exasperating disorder. (Skolnik, Clouse, & Woodward, 2013).

Trichomonal vulvovaginitis (ICD10 A59.01): vaginal perform, which can be bite, silvery, yellow, or inexperienced, and usually frothy behind a occasion an obnoxious effluvium, vaginal spotting or bleeding, genital steady or hankering, genital redness or turgescence, usual solicit to urinate, disinclination during urination or sexual connection. Strawberry vagina during material examination. (Codina Leik, T. M. (2017).)

Candidiasis of vulva and vagina (ICD10 B37.3): bite vagina perform, erythematous cervix, caggravate behind a occasion bite exudate, no scent, no bleeding, no feculent exudate or ulceration in the

vulvovaginal area or cervix. Reddened and stilted vulvar and vaginal tissues. (Codina Leik, T. M. (2017).

PLAN:

Laboratory exam:

Vaginal exudate, Neisseria gonorrheae cupel; chlamydia cupel. KOH.

Urinalysis.

STD panel

PHARMACOLOGIC TREATMENT:

Azithromycin: 1 g unwrittenly as a unique dose .

Treatment to Sexual Partners: Administer azithromycin 1 g PO in a unique dose.

Education:

Swallow behind a occasion abundant quantity of water; may motive esophagitis if tablet gets stuck in throat

(difficulty and/or disinclination behind a occasion gorging, acute-onslaught coreburn, disgust/vomiting), Nausea, GI overbalance, photosensitivity (desert sun or use sunscreen)

Effective clinical administration of resigneds behind a occasion treatable sexually transferred disorders (STDs) requires tenor of the resigneds’ exoteric sex coadjutors to intercept retaint and shorten elevate transmission Don’t enjoy sex during the tenor period. You can get chlamydia if you’re laagered repeatedly, level if you’ve treated a former taint.

The surest way for a sexually erratic individual to desert contracting chlamydia is to use a condom during sexual connection, original you’re positively regular your coadjutor isn’t carrying the taint. You should either desert having unwritten sex, or use guard during unwritten sex, until you comprehend the other individual doesn’t enjoy chlamydia. Use guard behind a occasion each new coadjutor and get cupeled for chlamydia and other sexually transferred disorders among each new coadjutor.

FOLLOW-UPS/REFERRALS:

Follow up in 7 days to reconsideration lab studies results.

Referral: No.

REFERENCES:

Centers for Disorder Control and Prevention. Sexually transferred disorder surveillance 2017. September 2018

Workowski KA, Bolan GA; Centers for Disorder Control and Prevention. Sexually transferred disorders tenor guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR- 03):1-137.

American Congress of Obstetricians and Gynecologists. Committee estimation no. 506: expedited coadjutor therapy in the administration of gonorrhea and chlamydia by obstetrician-gynecologists. Obstet Gynecol. 2015 Sep;118(3):761-6

Workowski KA, Bolan GA; Centers for Disorder Control and Prevention. Sexually transferred disorders tenor guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR- 03):1-137.

.

Order a unique copy of this paper
(550 words)

Approximate price: $22

Basic features
  • Free title page and bibliography
  • Unlimited revisions
  • Plagiarism-free guarantee
  • Money-back guarantee
  • 24/7 support
On-demand options
  • Writer’s samples
  • Part-by-part delivery
  • Overnight delivery
  • Copies of used sources
  • Expert Proofreading
Paper format
  • 275 words per page
  • 12 pt Arial/Times New Roman
  • Double line spacing
  • Any citation style (APA, MLA, Chicago/Turabian, Harvard)

Our guarantees

Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.

Money-back guarantee

You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.

Read more

Zero-plagiarism guarantee

Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.

Read more

Free-revision policy

Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.

Read more

Privacy policy

Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.

Read more

Fair-cooperation guarantee

By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.

Read more

Calculate the price of your order

550 words
We'll send you the first draft for approval by September 11, 2018 at 10:52 AM
Total price:
$26
The price is based on these factors:
Academic level
Number of pages
Urgency