Posted: November 1st, 2022

The patient is a 36-year-old woman

Centered Cleaning soap Word: Obstetric
Title:
Establishment:
Course:
Date:

Subjective (S)
Patient Title: MK Age: 36 years Race: Caucasian DOB: 5/23/1985
Chief Grievance (CC): Amenorrhea w/o ache
Purpose for Go to: Go to for Annual Examination
Historical past of Current Sickness (HPI): The patient is a 36-year-old woman who reported to the clinic with complaints of amenorrhea with out ache. The shopper reported she has a historical past of diabetes and he or she takes metformin to manage it. She additional reported she has a historical past of deficiency in vitamin D, dysmenorrhea, and menorrhagia with a common menstrual cycle.
Onset; Per week in the past
Location; Pelvic
Length; 5 to seven days
Character; Ache
Assuaging & Aggravating components; none
Radiation; N/A
Timing; Fixed
Severity; Reasonable
Previous Medical & surgical Historical past (PMH, PSH): She has a historical past of diabetes characterised by elevated HgbA1C 7.1 ranges and takes metformin to manage it. She additionally has a historical past of deficiency in vitamin D, reasonable dysmenorrhea, and menorrhagia with a common menstrual cycle. The final menstrual interval was on 11/12/2021 and the final feminine annual examination was on 12/28/2021.
Allergic reactions: None.
Household Historical past: None
Accidents: None
Hospitalization: None
Household Historical past: No historical past of most cancers, anemia, hypertension, or coronary heart illness.
Social Historical past: MK is a fortunately married woman. She lives along with her husband with 4 sons born on 1/2/2005 (three.3kg), 12/23/2008 (3kg), 2/23/2010 (three.5kg), and three/6/2016 (three.4kg). All of the sons had been delivered vaginally. She doesn’t smoke, use alcohol or abuse any illicit medicine or leisure medicine. She is unemployed and a keep house mum. She is a staunch Cristian.
Substance Abuse: She doesn’t take any type of drug together with caffeine, alcohol, smoking, or illicit medicine.
An infection Hx: None
Obstetrical Historical past: G14P40104. She has a historical past of reasonable dysmenorrhea and menorrhagia with a common menstrual cycle. She denies dyspareunia or intermenstrual bleeding. Nonetheless, she wishes to have future fertility. Denies historical past of UTI however latest lab outcomes reveal w/PCP (12/16/2021).
GYN Hx: Historical past of 1 irregular Pap, no colposcopy required
Sexual Historical past: She is sexually energetic with one companion (her husband) and denies utilizing any contraceptive.
Menarche: 12 years
Psychiatric Hx: Denies having any psychiatric situations up to now.
OBJECTIVE (O)
Constitutional: Appears wholesome and effectively nourished. Alert and oriented. Denies weight achieve, temper swings, fever, and fatigue.
HEENT: No headache, dizziness, ear discharge, neck swelling, latest infections, tinnitus, head trauma, or sore throat.
Cardiovascular: Denies palpitation, chest ache, angina, or speedy coronary heart price.
Integumentary: Denies hair thinning, hair loss, rashes, or itching.
Gastrointestinal: C/o nausea. Denies vomiting, change in bowel habits belly ache, meals intolerance, or diarrhea.
Genitourinary: Denies polyuria, nocturia, dysuria, urinary incontinence, or urgency.
Neurological: No head trauma or harm, headache cognitive decline or reminiscence loss, problem concentrating, or sensorimotor perform.
Musculoskeletal: Denies joint ache, no intermittent claudication, muscle pains, deformity, fractures, swelling, or stiffness.
Hematologic: Denies being anemic or having a blood, liver, or spleen situation.
Lymphatics: No enlarged lymph nodes on the neck, armpits, or groin.
Peripheral Vascular: No varicose veins, or tenderness on calves, legs, toes, or toes. Psychiatric: Denies historical past of psychiatric situation however experiences temper swings. Constitutional: Appearances to be wholesome and well-nourished. Alert and centered. Weight achieve, temper swings, fever, and fatigue are all denied.
HEENT: No dizziness, headache, ear discharge, neck swelling, latest infections, tinnitus, head trauma, or sore throat.
Cardiovascular: Refuses to acknowledge palpitation, chest ache, angina, or a speedy coronary heart price.
Hair thinning, hair loss, rashes, or itching are all denied.
C/o nausea, gastrointestinal. Denies any vomiting, bowel modifications, belly ache, meals intolerance, or diarrhea.
Denies polyuria, nocturia, dysuria, urinary incontinence, and urgency.
No head trauma or harm, cognitive decline or reminiscence loss, problem concentrating, or sensorimotor perform.
Musculoskeletal: There is no joint ache, intermittent claudication, muscle ache, deformity, fractures, swelling, or stiffness.
Hematologic: denies being anemic or having a drawback with the blood, liver, or spleen.
No enlarged lymph nodes within the neck, armpits, or groin.
There are not any varicose veins or tenderness within the calves, legs, toes, or toes. Psychiatric: Denies having a psychiatric situation however has temper swings.
Endocrine: Hx of diabetes and deficiency in vitamin D
Reproductive: Sexually energetic along with her husband. Denies utilizing safety.
Overview of System (ROS):
Bodily Examination: Very important Indicators; Ht – 66, Weight – 163lbs, BMI – 26.three, Temp – 98.2, BP – 100/65, oxygen saturation – 98%, and RR-18.
Head/EENT: Head; Normocephalic and atraumatic with hair thinning. Similar pupils, no nasal deviation. Dry oral mucosa, pure oropharynx. The neck is supple with no nodules. Eyes have white sclera and pink conjunctiva.
Cardiovascular: Common coronary heart price and rhythm.
Stomach: Spherical, comfortable and non-tender on palpitation. Bowel sounds on all quadrants.
Breasts: Regular bilaterally symmetrical with out plenty, dimpling, discharge, or redness.
Extremities: Regular with out clubbing, cyanosis, and edema. Palms and nails are regular. Ambulates with out problem
Neurological: Regular No gross sensory or motor deficits.
Lungs: Clear
Vagina: Regular. Vaginal vault unremarkable, with yellow-blood-tinged discharge. Irrigation
Exterior Genitalia: Regular, no redness, swelling, or redness. Regular hair distribution.
Vulva/Labia Majora: Moist, full, symmetrical, comfortable tissue, and homogenous. No warts, lesions, redness, or sores had been famous.
Clitoris: No redness or irritation was famous.
Cervix: Symmetric, midline, evenly distributed pink, and clean. Closed and non-tender.
Pelvic: Regular and intact perineum.
Uterus: Regular, regular place, common form, and no prolapse.
Urethra: Regular
Adnexa: Regular and deferred rectal.
Introitus: Parous
Pores and skin: No hair thinning, no patches, or pores and skin discoloration.
Psych: Maintains eye contact, seems her age. Dressed for the climate. Alert and oriented.
Assessment
• Leukorrhea – whitish or yellowish discharge
• Amenorrhea w/o ache, LMP 11/12/2021
• Urine being pregnant check (UPT) -negative at present
• Guidelines out early intrauterine being pregnant (IUP)
• Needs elective terminations of being pregnant (ETOP)
• Nausea
• Latest labs w/PCP 12/16/2021
• Historical past of elevated HgbA1C (7.1) – historical past of diabetes, taking metformin
• Historical past of deficiency in vitamin D.
• H/o reasonable dysmenorrhea, menorrhagia with common menstrual cycle
• Urinalysis (81002) – pH -5; particular gravity (SG)-1 and Purple blood cells (BLO) – optimistic.
Differential Analysis (DDx)
N89.eight: Leukorrhea
Leukorrhea or fluor albus is a vaginal discharge, which may be pathological or physiological. Physiological leukorrhea happens throughout the menstrual course of characterised by whitish to clear coloured and odorless discharge whereas pathological leukorrhea ranges from yellowish/greenish/greyish, smells fishy/foul scent vaginal discharge in giant quantities inflicting itching, erythema, edema, burning sensation, dyspareunia and dysuria (Trilisnawati et al., 2018). Pathological leukorrhea is a non-infection dysfunction that causes vaginitis together with overseas our bodies, allergic vaginitis, and vulvar vestibulitis inflicting irritation leading to disagreeable odor and extra exudate in feminine sufferers. The scientific manifestation of leukorrhea in ladies consists of vaginal discharge with itchiness. The discharge is a skinny liquid and typically thick or sticky starting from whitish, greyish-white, yellowish, greenish, reddish, darkish coloured, or rustic (Trilisnawati et al., 2018). Different related signs embody anorexia, constipation, and fatigue.
The analysis includes diagnostic procedures together with bodily examination, anamnesis, and supportive examination comparable to vaginal pH whiff/KOH check, and microbiologic examination. The Chief complaints related to leukorrhea embody elevated quantity in discharge, irregular odor, recognizing, itchiness, burning sensation, and dyspareunia. Different components to contemplate embody decrease belly ache, frequency of intercourse, and hx of STD or companion intercourse. Homogeneous adherent white discharge, vaginal pH above four.5, amine odor after discharge, and Nugent rating above four supporting examinations verify the analysis of leukorrhea. The patient meets the standards for leukorrhea upon presenting yellowish discharge, blood-tinged discharge (RB; +ve), vaginal pH above four.5 (5), amine odor, and pelvic ache.
N76.zero: Bacterial Vaginitis (BV)
BV is attributable to an overgrowth of regular vaginal flora and is usually characterised by elevated fish-like odor vaginal discharge usually whitish or grey. Though BV is not thought of a sexually transmitted an infection (STI), the micro organism can unfold amongst sexually energetic people as a consequence of alteration of pure bacterial flora steadiness inside the vagina resulting in the event of BV (Kairys & Garg, 2022). Ideally, a diminished variety of regular hydrogen peroxide produce Lactobacilli with an overgrowth of anaerobic micro organism inflicting BV. Majority of ladies with BV current malodorous vaginal discharge particularly after sexual activity, though the situation may be asymptomatic. Further signs embody dysuria, dyspareunia, and vaginal pruritus (Kairys & Garg, 2022). As clinicians, it is essential to elicit pertinent historical past on danger components comparable to a historical past of BV, latest antibiotic use, vaginal douching, use of an intrauterine system, and the variety of sexual companions. A correct examination includes pelvic examination is wanted to rule out presenting situations comparable to trichomoniasis, cervicitis, herpes simplex virus, candidiasis, chlamydia, and gonorrhea. Assessing pelvic examination, fever, and historical past of STI helps in ruling out different critical situations or differential diagnoses. A clue cell is a dependable diagnostic signal for BV by analyzing vaginal fluid beneath a microscope. The Amsel standards Help in the analysis of BV characterised by a skinny white, a yellow, homogenous discharge vaginal fluid pH better than four.5, the discharge of a fishy odor, no vulva irritation or discomfort or itch, and clue cells on microscopy (Kairys & Garg, 2022; Sim et al., 2020). Nonetheless, the patient doesn’t meet the standards for analysis because the vaginal dysfunction is odorless.
N94.6: Dysmenorrhea
The patient could possibly be identified with dysmenorrhea. Dysmenorrhea is outlined as painful month-to-month bleeding it will possibly both be major or secondary. Main dysmenorrhea is characterised by decrease belly ache throughout the menstrual cycle whereas secondary dysmenorrhea is related to different pathological components inside or exterior the uterus: Ladies throughout reproductive age expertise emotional, psychological, and practical well being impressions and related danger components comparable to nulliparity, excessive BMI, early menarche age, household historical past of dysmenorrhea and longer menstrual circulation (Nagy & Khan, 2021). Medical manifestations embody nausea, fatigue, vomiting, headache, and diarrhea. As such, a complete historical past is wanted to ascertain a analysis together with a historical past of ache, location, period, and character. Typical widespread findings indicative of secondary dysmenorrhea embody older age above 25 years, vaginal discharge whitish grey in colour as a consequence of inflammatory ailments, pelvic plenty, and different related components infertility, dysuria, dyspareunia, dyschezia, nodularity, adnexal plenty, and tenderness as a consequence of non-gynecological etiology or endometriosis (Nagy & Khan, 2021). Subsequently, the analysis course of includes being pregnant exams, ultrasound, and danger of STIs, scientific examination to rule out malignancy cervical cytology samples, Doppler ultrasonography, and laparoscopy. Though the patient is chubby (BMI -26.three) and has a foul-smelling whitish discharge, nausea, older age, pelvic ache, and a historical past of dysmenorrhea, she doesn’t meet the standards for dysmenorrhea since she has no pelvic plenty intact adnexal plenty, and no tenderness.
Plan
The administration of the patient’s situation includes a prescription of azithromycin 1 gram single dose orally or doxycycline 100 mg twice a day orally for seven days and patient schooling on genital space hygiene (Trilisnawati et al., 2018). Patient schooling will even use of condoms, delayed sexual activity for a week after finishing therapy, secure intercourse, minimizing publicity to the solar which may trigger photosensitivity, avoiding tight artificial clothes, and douching. The patient must be educated on the scientific manifestation of regular physiologic or pathological prevalence and manifestation associated to vaginal and the way to differentiate them together with using level of care instruments comparable to narrow-spectrum pH paper in assessing vaginal an infection (Sim et al., 2020). The plan concerned a number of procedures comparable to irrigation medicate vagina (57150), and ultrasounds comparable to transvaginal (76830), pelvic (76856), and duplex scan belly and pelvic (93976). Different laboratory and diagnostic exams included urinalysis (81002), venipuncture (36415), being pregnant check (81025), Pap assortment (Q0091), and breast examination (G0101).
Performing a urine tradition on vaginal swabs helps in ruling out a analysis of BV or detect detection of BV-associated microorganisms and different issues comparable to Gardnerella vaginalis (G. vaginalis), Prevotella bivia (P. bivia), and Lactobacillus crispatus (L. crispatus) (Naicker et al., 2021). The patient was referred to Dr. Irina Mikheyeva, a gynecologist for ETOP session as a commonplace therapy for diagnoses of retained overseas our bodies, cervical ectopy, suspected tumors within the genital tract, or higher an infection. The referral will Help in the analysis of recurrent vulvovaginal an infection and failure of therapy methods (Sim et al., 2020). The prognosis within the administration of leukorrhea includes examination and therapy processes making use of a syndromic strategy particularly if related to hormonal components. The patient is chubby (BMI – 26.three) and has a historical past of diabetes therefore the necessity for psych counseling, osteoporosis screening, dietary counseling, bodily exercise counseling, Pap pelvic examination, and BMI follow-up plan. The patient is a new shopper beneath CPT code 99385 aged between 18-39, suggested to take a flu vaccine beneath CPT code 99203 and go to the clinic after two weeks. Chubby sufferers are at larger danger of growing osteoporosis which impacts the myoskeletal system characterised by low bone density and diminished muscle mass and power therefore the necessity for screening. As such, vitamin counseling together with consumption of protein and vitamin D consumption together with resistance and endurance workouts prevents osteoporosis and administration of diabetes (Papadopoulou et al., 2021).

References
Kairys N, & Garg M. [2022) Bacterial Vaginosis. StatPearls [Internet]. Treasure Island (FL). StatPearls Publishing; Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK459216/
Nagy, H., & Khan, M. A. (2021). Dysmenorrhea. In StatPearls [Internet]. StatPearls Publishing. Retrieved from https://www.statpearls.com/ArticleLibrary/viewarticle/20798
Naicker, D., Ramsuran, V., Naicker, M., Dessai, F., Giandhari, J., Tinarwo, P., & Abbai, N. (2021). Robust correlation between urine and vaginal swab samples for bacterial vaginosis. Southern African Journal of Infectious Ailments, 36(1). https://doi.org/10.4102%2Fsajid.v36i1.199
Papadopoulou, S. Ok., Papadimitriou, Ok., Voulgaridou, G., Georgaki, E., Tsotidou, E., Zantidou, O., & Papandreou, D. (2021). Train and Vitamin Affect on Osteoporosis and Sarcopenia—The Incidence of Osteosarcopenia: A Narrative Overview. Vitamins, 13(12), 4499. https://doi.org/10.11622%2Fsmedj.2020088
Sim, M., Logan, S., & Goh, L. H. (2020). Vaginal discharge: analysis and administration in major care. Singapore medical journal, 61(6), 297.
Sim, M., Logan, S., & Goh, L. H. (2020). Vaginal discharge: analysis and administration in major care. Singapore medical journal, 61(6), 297. https://doi.org/10.11622%2Fsmedj.2020088
Trilisnawati, D., Izazi Hari Purwoko, Mutia Devi, Suroso Adi Nugroho, Fitriani, & Theresia L. Toruan. (2021). Etiology, Analysis, and Remedy of Leukorrhea. Bioscientia Medicina : Journal of Biomedicine and Translational Analysis, 5(6), 571-590. https://doi.org/10.32539/bsm.v5i6.323

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