Patient Initials MB
Subjective Data: A female in her late 20s, that is, 28 years of age experiencing frequency, burning, and pain through her two-day history when she urinates; other effects are increased abdominal pains with a vaginal discharge through her one week past. Also, complains attached to urinary symptoms that can be attributed to a previous urinary tract infection (UTIs) but have lasted for two days only. However, a severe abdominal pain seems to be the larger issue and an additional brown, foul-smelling discharge, and this is after she got involved with another person without the use of protection.
Chief Complaint: “I am feeling very painful with a burning sensation; I feel very painful on my lower abdomen, and when I go to urinate, I get this brown foul smell coming out of my vagina inform of discharge this was after I had unprotected intercourse.”
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History of Present Illness: She had not had a history of the symptoms before, but a week ago she began experiencing the signs of frequency, burning, and pain. The signs began some two days ago; a recorded severe pain in the abdomen with discharging foul smell after unprotected intercourse.
PMH/Medical/Surgical History:
Medical history : Having recurrent UTIs has had three of them this year; gonorrhea X(II), chlamydia X(I); and lastly Gravida IV ( Coleman, 2017)
Allergies: NKDA
Surgical History: she has had a Tubal Ligation in two years ago.
Family/social History Family: she is single; has had some multiple male sexual partners; currently settled with another new boyfriend and her three children.
Social: She denies smoking and consumption of other drugs such as alcohol.
Medication History: Presently she does not have any.
Past medication: She was using Trimethoprim (TOM)/Sulfamethoxazole (SMX) but is largely recognized as Bactrim. These were the labels used for: Infections she had before for Urinary tract; but an unlabeled use for Chlamydia infections ( Galiczewski & Shurpin, 2017) . The last pap she had was six months ago but denies ever having breast discharge. This is a positive for her urine looking dark.
Significant Family History: she is single; has had some multiple male sexual partners; currently settled with another new boyfriend and her three children.
Social: She says that, she is not involved with any kind of drug that is, smoking, alcohol and any other types of drugs. She readily admits to having some financial troubles in her home. However, she denies having any kind of affiliations with religion. Readily admits having some poor feeding habits and does not take part in exercises. She also denies having undergone any kind of physical or mental abuse.
Review of Symptoms: The last pap she had, it had been six months ago, but denies ever having breast discharge. This is positive for her urine looking dark. Feeling very painful with a burning sensation; Feeling very painful on her lower abdomen and when going to urinate she gets this brown foul smell coming out of her vagina a form of discharge this was after she had unprotected intercourse. General: A woman aged 28 years old who appears to have mild distress. Integumentary: She had a very clean dry and intact; Head: She had an oral cavity that did not have lesions, A and O, she also had TM that did not appear to have inflammation; Eyes: there were no signs of nystagmus( Trautner at al., 2017) ; ENT: she had an oral cavity that did not have lesions, and a TM I the same order without inflammation; Cardiovascular; she had a normal regulated rate of rhythm which was S1 and S2; Respiratory: she had a clear respiratory bilaterally; Gastrointestinal: she had an unremarkable one; Genitourinary: she also had an unremarkable one Musculoskeletal: she had an unremarkable one; Neurological: She had an A and O of X3, but her cranial nerves were perfectly intact; Psychologic: She was in denial.
Objective Data
Vital Signs: BP 100/80, HR 80, RR 16, T 99.7 F, Wt 120, Ht 5’ 0”
Physical Assessment Findings: (Includes full head to toe review)
Gen: Female in moderate distress.
HEENT: WNL.
Cardio: Regular rate and rhythm normal S1 and S2.
Chest: WNL. Abd: soft, tender, increased suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul-smelling vaginal drainage.
Rectal: WNL.
Laboratory and Diagnostic
Testing Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2% UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs 10- 15, RBC 0-1 Urine gram stain – Gram negative rods Vaginal discharge culture: Gram negative diplococci, Neisseria gonorrhoeae, sensitivities pending Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative
Assessment: (Include at least three priority diagnosis with ICD-10 codes. Please place in the order of priority.) She had PE caused by a possible Trauma that is IDC-10-CM T78, T79: Another CHF with ICD-10-CM with 150.42: She had moderate asthma: ICD-10-CM J45.40. (Data was retrieved from ICD10Data.com)
The patient is a 28 year old female and experiences CHF that is constantly consistent with edema, and has experienced suffering of moderate asthma that is, she has experienced attacks consistent with four to five times in a month and she is a consistent user of the inhaler, she could also be a victim of the pulmonary embolism since she had or was experiencing trauma that was before.
Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided). Females are mostly affected by UTIs, since that is their natural anatomy. Also, they have a short urethra which can be passed to have proximity to their anus. After assessing pain and also the possible dark color of the urine appearance odor and other features such as the mental status and body temperature it would be prudent to make discontinuation of the catheter ( Eure et al., 2017) .
Making appropriate following for the female patient would be very necessary to asses if their treatment is working well or can be changed in the course of their diagnosis. A scheduled routine voiding is necessary for the patient to make sure that they are emptying the bladder to its totality in a bid to make sure that it is clear. Also, the output helps in eliminating the bacteria. Appropriate medicines will be issued to the female which will be in the form of antibiotics, antispasmodics, and other analgesics to assist the patient in eliminating the UTI infection and possible relief from the disease. All the process diagnosis will be useful in relieving the patient.
References
Coleman, T. (2017). Assessing the need for urinary catheters daily and reducing CAUTI rates nation-wide.
Eure, T., LaPlace, L. L., Melchreit, R., Maloney, M., Lynfield, R., Whitten, T., ... & Thompson, D. (2017). Measuring Antibiotic Appropriateness for Urinary Tract Infections in Nursing Home Residents. infection control & hospital epidemiology , 38 (8), 998-1001.
Galiczewski, J. M., & Shurpin, K. M. (2017). An intervention to improve the catheter associated urinary tract infection rate in a medical intensive care unit: direct observation of catheter insertion procedure. Intensive and Critical Care Nursing , 40 , 26-34.
Trautner, B. W., Greene, M. T., Krein, S. L., Wald, H. L., Saint, S., Rolle, A. J., ... & Mody, L. (2017). Infection prevention and antimicrobial stewardship knowledge for selected infections among nursing home personnel. infection control & hospital epidemiology , 38 (1), 83-88.
