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Assignment NR 602 Wk 7 Chunky Vaginal Discharge Case

Assignment: NR 602 Wk 7 Chunky Vaginal Discharge Case

H.C: Age 30, Sex: Female, Race: Caucasian, Insurance: yes

S.

CC: “My vagina itches really bad, it burns when I pee, and I am having some white discharge that is chunky.”

“I have noticed my vagina smells really bad after I have sex and I have a weird milk like discharge too.”

“I am having a lot of vaginal discharge that is green, frothy, and it smells bad. Also, my vagina is irritated and sore.”

HPI: 30-year-old female presents with complaints of vaginal itching, burning with urination, and white, chunky discharge that has been going on for 8 days now. She states that it itches so bad that it wakes her up at night and that her vagina is really red from all the scratching. She has tried Monistat  OTC, the 3-day treatment option with a topical cream but her symptoms have not improved. She also admits to using a vinegar and water solution that she applies externally to help relieve the itching

30-year-old female presents with complaints of malodorous, milky vaginal discharge that is most noticeable after she has intercourse. She is in a monogamous relationship and her partner is the one who pointed out the smell about 3 days ago. She admits that they do not use condoms. She reports trying a vaginal douche but was not sure if she picked the right one because it did not help her symptoms.

30-year-old female presents with complaints of increased vaginal discharge that is malodorous, green, and frothy that she discovered 4 days ago. She also has complaints of itching, mainly around the labia minora, that started 2 days ago and is now really irritated and she has burning when she urinates as well. She admits that she has a few different sex partners and she is not always diligent when it comes to condom use. She states that she has tried a few OTC options but nothing makes the discharge or irritation go away.

Current Medications:

OTC Ibuprofen on occasion when she has menstrual cramps or minor headaches

Multivitamin daily

Vitamin C 1000 mg PO BID

Allergies:

NKDA

Mild tape allergy

PMH:

UTIs

Influenza

No surgeries

No major illnesses or hospitalizations.

Social Hx:

H.C. works as interior designer. She lives alone in a townhouse. She has 1 small dog and 2 cats. She denies cigarette smoking and illicit drug use. She admits to drinking alcohol, mostly on the weekends with her friends but she may have some wine during the week as well. She typically works out 4 to 6 days a week and sleeps maybe 6 hours a night.

Fam Hx:

Assignment NR 602 Wk 7 Chunky Vaginal Discharge Case

Assignment NR 602 Wk 7 Chunky Vaginal Discharge Case

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Father: Alive, 68; hyperlipidemia

Mother: Alive, 65; HTN, anxiety

Siblings: One brother and two sisters, all in good health

ROS

Constitutional: No weight loss, chills, fever, or weakness.

HEENT: Head: Denies any dizziness, head congestion, or head injury.  Eyes: Denies visual loss, double vision, and blurred vision. Ears: Denies hearing loss or any ringing in the ears. Nose: Denies any nasal congestion or post-nasal drip. Throat: Denies any sore throat or difficulty swallowing.

Cardiovascular: Denies any chest pain, chest tightness, chest pressure, or chest discomfort. Denies any palpitations and edema.

Respiratory: Denies any shortness of breath, cough, wheezing, or asthma. 

Gastrointestinal: Denies back pain. Denies any abdominal pain, nausea, vomiting, diarrhea, constipation, bloody or black stools, heartburn, or indigestion.

Genitourinary: The patient has complaints of extreme vulvar pruritus that is so bad it wakes her up at night, vulvar erythema, dysuria, and white, chunky vaginal discharge. The patient denies any malodorous smell associated with the vaginal discharge. Pt denies any hematuria or urinary frequency or urgency.

The patient has complaints of malodorous, milky vaginal discharge that is most noticeable after she has intercourse. The patient denies any hematuria, dysuria, urinary frequency or urgency.

The patient complains of increased vaginal discharge that is malodorous, green, and frothy. She also has complaints of vaginal itching and irritation, and dysuria. The patient denies any hematuria, urinary frequency or urgency.

 

O.

 

Vital Signs: HR: 69 RR: 15 BP: 116/ O2 Sats: 99% Temperature: 97.9 Weight: 138 Height: 5’11” BMI: 19.2

General: The patient is alert, oriented, and cooperative. However, the patient is visibly uncomfortable.

HEENT: Head: : Normocephalic, atraumatic, no masses visualized or palpated. Hair is thick and is evenly distribution throughout scalp. Eyebrows symmetrical. Eyes: Pupils equal, round, reactive to light, red reflexes noted bilaterally. Conjunctiva pink, sclera white. Ears: Tympanic membranes gray and intact with light reflex noted, no redness, tenderness, or bulging noted. Pinna and tragus nontender. Hearing WNL. Nose: Nostrils clear, turbinate’s clear and without narrowing, no redness, swelling, or drainage noted.  Throat/Mouth: Oropharynx clear, moist, and pink, uvula noted midline, no redness, edema, lesions, cracks or dryness noted. Teeth in good repair, no cavities noted. No tonsillar hypertrophy. 

Neck: Supple. No thyromegaly. No enlarged lymph nodes or masses palpated. No bruit.

Cardiovascular: Normal heart sounds noted on auscultation in all 4 quadrants. Regular rate and rhythm noted. No murmur, rub, or gallop noted. 

Respiratory: All lung fields clear on auscultation and percussion. Lung expansion symmetrical, no consolidation noted. No SOB noted upon exertion.

Gastrointestinal: Bowel sounds present in all quadrants. Vascular sounds negative. No swelling or pain noted on palpation. No organ enlargement noted. No CVA tenderness.

Pelvic Exam: A pelvic exam was performed based on symptoms reported by the patient. Erythematous, excoriated vulva that includes the labia minor noted. Vaginal discharge is found to be thick, white, and curdy without odor. The vaginal canal was visualized and noted to be erythematous. Cervix visualized and noted to be pink, midline, smooth without excoriation, parous os. A vaginal culture was obtained.

A pelvic exam was performed based on symptoms reported by the patient. The vulva and labia minora are without erythema. The vaginal canal was visualized, no erythema noted. A malodorous, milky vaginal discharge was noted. Cervix visualized and noted to be pink, midline, smooth without excoriation, parous os. A vaginal culture was obtained.

A pelvic exam was performed based on symptoms reported by the patient. The vulva and labia minor are erythematous but without excoriation. Vaginal discharge is found to be malodorous, green, and frothy. The vaginal canal was visualized, erythema noted. The cervix was visualized, multiple petechiae noted.

 

Diagnostics:

Vaginal pH of 4.0

Vaginal secretions visualized under microscope using both wet prep and KOH solution.

Vaginal culture also sent to the lab.

 

Vaginal pH of 5.0

Vaginal culture obtained. Wet mount performed with clue cells visualized under microscopy.

Whiff test performed.

 

Vaginal pH of 6.5

Vaginal culture obtained. Polymorphonuclear cells and motile flagellates visualized under microscopy.

Important information for writing discussion questions and participation

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

  • Your response needs to be a minimum of 150 words (not including your list of references)
  • There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
  • Include in-text citations in your response
  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

  • A minimum of 6 responses per week, on at least 3 days of the week.
  • Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
  • Each response needs to be at least 75 words in length (does not include your list of references)
  • Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
  • Follow APA 7th edition
  • Points will be deducted if the above is not followed

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to.

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

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