Discussion Advance Primary Care of Family

Discussion Advance Primary Care of Family

Make a discussion about the diagnosis of the case related to the case given. More than 250 words and 2 or more references( initial and the reference page are not included in the 250 or more words)

.Case

Age: 45 Sex: F

Allergies: NKA Advanced Directives: Full Codeas neede

SUBJECTIVE

CC: ” I have vaginal bleeding and pelvic pain.”

HPI: Pleasant Hispanic women, 45 y/o, G4P2A2T2, married, sexually active, heterosexual, no history of STDs, that came to the clinic with the main complains of bleeding and pelvic pain, associated with abdominal distention and passing clots. Patient reports one year ago she started with irregular menstrual cycles. Previous MP was 5 months ago, and LMP started few days ago, associated with nausea and vomiting. Her menstrual cycles used to occur regularly in 28-day intervals and last 5-6 days. Patient reports used condom as a contraceptive method and for STD’s prevention. Her last pap smear was last year, unremarkable result at this time. Onset: 5 days ago Location: pelvic and lower abdomen Duration: constant Characteristics: painful, pressure pain. Aggravating Factors: Physical Activities Relieving Factors: N/A Treatment: None

Current Medications: None

PMH

Medication Intolerances: None.

Chronic Illnesses/Major traumas: None.

Screening Hx/Immunizations Hx: Up to date. Influenza last year.

Hospitalizations/Surgeries: Right ankle Sx.

Family History

Father- 75 years old, with no PMHx.

Mother- 68 years old, with PMHx of DM.

Social History

AL is a hair stylist at a hair salon that lives with her husband and two sons. She denies cigarette smoking and been exposed to cigarette at home, reports 1-2 cup of coffee daily. Patient denies alcohol consumption and recreational drugs. Patient states been sexually active with her husband with condom use as contraceptive and preventing std’s. Menarche at 13 years old.

ROS

General: Denies chills, night sweats, fatigue, or recent weight changes. Reports cold intolerance. Cardiovascular: Denies palpitations, claudication, chest pain, or orthopnea.

Skin: Denies skin rash, no wound, no change on skin color or texture, no change in a mole, no unusual growth, no dry skin, no itching, no jaundice.

Respiratory: Denies painful breathing, SOB, abnormal sputum production, cough. Denies recall taking a TB skin test,

Eyes: Denies visual loss, double vision, or blurred vision. Patient states has no history or cataracts or glaucoma.

GI: Patient denies abdominal pain, difficulty swallowing, vomiting, intolerance to food, appetite changes, or stool changes.

Ears: Denies ear pain, ear infections, or tinnitus. Denies hearing loss.

GU/ Gynecological: Patient denies urinary urgency, frequency, dysuria, odorous urine and suprapubic pain. Reports vaginal bleeding and pelvic pain. Patient reports voiding at 0830AM LMP: 01/31/21

Nose/ Mouth/ Throat: Denies nasal pain or discharge, congestion, or other sinus problem. Refutes throat swelling or pain.

Musculoskeletal: Denies limits to ROM, swelling, muscle pain, or warm joints.

Breast: No skin changes, no rashes, no lesions, no dimpling, no nipple retraction.

Neurological: Patient denies rebuts coordination difficulties, paralysis, tremors, seizures, or syncope.

Hemo/ Lymph/ Endo: Foregone

Psychiatric: Denies problems with coordination, nervousness, feelings of irritability, mood changes, anxiety, or depressive symptoms.

OBJECTIVE

Weight: 81.8kg Height: 5’6’’ BMI: 29.1 Temp: 98.7 BP: 132/91

Pulse: 73 Resp: 16 Pulse Ox: 100%

PHYSICAL EXAMINATION

General Appearance: Well-developed and dressed/groomed, pleasant demeanor, speech clear. Appears to be without discomfort, does not look distressed. Pain level: 5/10. Normal general appearance. Patient is awake, oriented, and alert. Well-developed and nourished. Patient keeps a normal position and posture without deformities. Patient speaks clear and appropriate in native language. Excellent personal hygiene. No acute distress.

Skin: Skin warm, wnl color and moist. Normal skin turgor. No lesions, redness, swelling or cyanosis noticed. Capillary refill less than 3 sec.

HEENT: Head Normocephalic with normal hair distribution. No facial swelling noted. Eyes: PERRLA; EOMI. Fundi benign. Ears: TMs intact with no erythema; Nose: Mucous membranes pink and moist. Nasopharynx without erythema, exudates, or lesions; Mouth: good dentition, no missing teeth, tongue in normal position, Gag Reflex intact. Bilateral neck swelling to the side below of the trachea.

Cardiovascular: S1 and S2 normal without MRG. No extra murmurs or sound present. No carotid bruits. No JVD.

Respiratory Symmetric chest wall. Respirations even and unlabored; lungs clear to auscultation bilaterally. No fremitus.

Gastrointestinal Abdomen soft, no tenderness, no masses, Bowel sounds presents and normal in the four quadrants. No abnormal aortic pulsations. No ascites. No splenomegaly, no hepatomegaly, nor hernia. No muscle rigidity. No rebound, no guarding. No painful to palpation.

Breast Size: small, symmetry. No skin changes, no rashes, no lesions, no dimpling, no nipple retraction, no tenderness to palpation. Axilla WNL

Genitourinary No inguinal hernias or CVA tenderness. Pelvis examination: Normal appearing external female genitalia, normal vaginal epithelium, no abnormal discharge. Normal appearing cervix. Bimanual: No CMT. No palpable adnexal masses.

Musculoskeletal ROM WNL without crepitus or pain except in Left Upper Arm ROM limited due to pain.

Neurological Patient AAOX4. Speech clear and coherent. Cranial nerves I-XII intact. Motor and sensory levels intact.

Psychiatric Patient appears to have normal affect and is able to follow commands. No signs of anxiety or depression noticed.

Labs Tests

CBC with differential

CMP7

Urinalysis

Special Tests

Transvaginal US

Diagnosis –

Salpingitis, Unspecified (ICD10 N70.91)

Differential Diagnosis

– Endometriosis

– Ovarian Cyst

– Uterine fibroids

Plan

– Doxycycline 100mg, PO, q12hr, x 5 days

– Ketoralac 10mg, PO, q8hr, PRN for pain

– Referral to OB/GYN

Teaching

– Use of condoms during sexual intercourse.

– Avoid douching, they can push the bacteria into pelvic organs and cause infection.

– Using IUD for contraceptive also increases the risks.

– Sex partner also needs to be treated.

References

1.Codina Leik, M. T. (2018). Family Nurse Practitioner Certification Intensive Review (3rd ed.).

2. Dr. Allan H. Goroll MD MACP; Dr. Albert G. Mulley Jr. MD MPP. (2014). Primary Care Medicine: Office Evaluation and Management of the Adult Patient. 7th Ed.

3. Lucille A. Joel EdD APN FAAN. (2017). Advanced Practice Nursing: Essentials for Role Development. Milner D, Danny A. (2015). Diagnostic Pathology: “The link between HPV and Cancer”.CD. September 30. 2015.Retreived 11 August 2016.

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