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Women Health Module 6 Clinical Discussion

This week, the challenges faced were more of maintaining the level of competence and excellence in the clinical encounters and office notes documentations. Success has been made in analyzing the cases and reaching a good differential diagnosis and most common definitive diagnosis.

This week’s case is a 37-year-old female who presents to the clinic with vaginal discharge, which is white with a “yeast/different odor smell,” onset 5 days ago. No alleviating or aggravating factors. No other concerns currently. Her last menstrual period was 08/27/2021. The patient is currently not taking any medications except oral contraceptive pills. No known drug allergies. The past medical history is relevant only for recurrent urinary tract infections. Family medical history is irrelevant as mother and father are healthy. The patient is up to date with all vaccinations and the last PAP smear was in 2020 and it was completely normal. ROS: General: No weight change, generally healthy, no change in strength or exercise tolerance. Head: No headaches, no vertigo, no injury. Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain. Ears: No change in hearing, no tinnitus, no bleeding, no vertigo. Nose: No epistaxis, no coryza, no obstruction, no discharge. Mouth: No dental difficulties, no gingival bleeding. Neck: No stiffness, no pain, no tenderness, no noted masses. Chest: No dyspnea, no wheezing, no hemoptysis. Heart: No chest pains, no palpitations, no syncope, no orthopnea. Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena. GU: Vaginal discharge with odor, no urinary urgency, no dysuria, no change in nature of urine. Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesia or numbness. Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia. Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content. Denies fever, chills, nausea, vomiting, foreign travel. Not exposed to similar sick contacts. The physical exam is relevant for vaginal redness and whitish discharge. Vitals were within normal limits. In Assessment, urinalysis was normal, and the patient was asked if she wants to have a smear and culture of the vaginal discharge, but she was educated she will be put on treatment anyway since the signs are mostly indicative of fungal infection and the patient declined. The care plan for this patient was to advise to Increase fluids, rest, avoid caffeine, sugar-free cranberry juice, avoid overheating or being in sun for prolonged periods, urinate after sexual activity, avoid bubble baths, irritating soaps, sprays, wipe from front to back (Dlugasch, Story, 2021, p.588). The patient was also advised to avoid prolonged use of not-needed antibiotics and to eat yogurt during the treatment given. Also, the patient was advised to avoid vaginal products and to change the oral contraceptive pills since they might be causing this as well. The differential diagnosis includes vaginal candidiasis, urinary tract infections, and sexually transmitted diseases (Schuiling & Likis, 2022, p.414).

This week’s clinical experience was very useful since not just a thorough differential diagnosis was needed as in this case. But also, a thorough investigation of the causes of the current problem was conducted to see the incriminated cause of the patient’s definitive diagnosis.  

References

Dlugasch, L., & Story, L. (2021). Applied pathophysiology for the advanced practice nurse. Jones & Bartlett Learning.

Schuiling, K. D., Likis, F. E. (2022). Gynecologic Health Care with an Introduction to Prenatal and Postpartum Care (4th Ed). Jones & Bartlett Learning, Burlington, MA. ISBN: 9781284182347