NR 602 Week 2 Activity-Submission: iHuman Case 2

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Week 2: Submission: iHuman Case 2 Re-submit Assignment • Due Nov 8 by 11:59pm • Points 75 • Submitting a file upload Once you have completed the iHuman Case on STI... , submit your Case Study completion score sheet here. You may resubmit your completion score sheet as needed. If you have not completed the iHuman Activity yet, please go to the Week 2: Activity: iHuman Case on STI assignment, for assignment requirement and access to iHuman. In NR602, iHuman assignments will be assessed on the following areas: History Taking, Physical Exam, Differential Diagnoses, Rank diagnoses, MNM (must not miss) Diagnoses, Order tests, Final Diagnosis, Management Plan. Each of these sections must be completed including the EMR section for the assignment to be considered complete. A score of 80% or better is your target with this assignment. You will have (2) two attempts; the highest score of two attempts will be taken as the final grade. Observations: Discharge- yellow, kind of mucousy, kind of creamy some smelly Skin: Pink, warm, moist CC: Burning during voiding and vaginal discharge HPI (History of Present Illness): Patient presents with a 2-day history of on urination and urinary frequency. She denies fever, chills, myalgia etc. She denies any prior history of UTI's, however, does have a new boyfriend and they have been very sexually active. PMH (Previous Medical History): Allergies: NKDA Othe r active p ro bl e ms: None Me dical , surgical , obst e t r i c , hospital i zatio ns: None Pre ve ntive He a l th: Last Pap smear 1 year ago: no Hx of abnormal results Previous screening for STDs Immunizati ons: No previous HPV vaccination General immunization status: the patient thinks she is up to date. Medications: Oral contraceptive pills (OCP): ethinyl estradiol/drospirenone Ibuprofen for menstrual cramps Family History: Mother: diabetes mellitus (DM) Father: hypertension (HTN), coronary artery disease (CAD), hyperlipidemia Older sister: Alive and well Social History: Works as a consultant; travels frequently Alcohol: 1 to 2 times per week; 4 to 5 drinks per occasion No other substance use Previous-smoker status; approximate 2-pack-year Hx ROS (Review of System): General / Constitutional: Normal, no complaints Sk in/ Bre ast: Normal, no complaints HEEN T & N e ck : Normal, no complaints Cardiovascul ar: Normal, no complaints Re spiratory: Normal, no complaints Normal, no complaints Ge nitouri nary: Describes pain with urination and urinary urgency Normal, no complaints Normal, no complaints Normal, no complaints Normal, no complaints Normal, no complaints Normal, no complaints Vital Signs: Abdome n/ Gastroi nte s t inal : Muscul osk el e tal : N e urol ogical : Al l e rgic/ Immunol ogic: L ymphatic/ Endocri ne : He matol ogic: Psychol ogical : Temp:98.6 FPulse:64, rhythm: regularBP:left: 118/62Respiration:12, effort: unlabored Physical Exam: Weight 134.0 pounds Sk in/ Bre ast: No pallor, jaundice, lesions, rashes Breasts normal, no nodules or masses No breast discharge HEEN T & N e ck : Normocephalic; atraumatic PERRLA Optic fundae: no papilledema or vascular pathology Sinuses nontender to light percussion No temporal artery tenderness Thyroid WNL Full cervical-spine ROM No cervical paraspinal muscular tenderness to palpation Cardiovascul ar: RRR w/o murmur or gallop Re spiratory: Clear bilaterally to auscultation and percussion Abdome n/ Gastroi nte s t inal : Soft, non-tender, non-distended. Normal bowel sounds. No suprapubic tenderness. No costovertebral angle tenderness (CVA) tenderness. Ge nitouri nary: No labial ulcerations or lesions. Vaginal walls pink without excoriations. Bimanual exam without cervical motion tenderness. No discharge Muscul osk el e tal : Deferred N e urol ogical : Deferred Al l e rgic/ Immunol ogic: Deferred L ymphatic/ Endocri ne : Thyroid normal Tests: UA: abnormal, suggestive of UTI Clean Catch for urine culture obtained - results pending Management: 1. Patient was started on empiric therapy for UTI with Bactrim • Suggested she can reduce the symptoms with lots of fluids, particularly cranberry juice • Sexually related UTI can be reduced in frequency with post-coital urination • F/U prn [Show More]

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