“ I have had burning, itching, and soreness...”
nikkyvu
CaseStudy_Ms_Lee_2024.docx
Chief concern: “ I have had burning, itching, and soreness in my vaginal.”
HPI: This is a 79-year-old African American female with PMH of HTN, NIDDM2, GOUT, Hypothyroidism, HLD, Carpal tunnel syndrome to both wrist with bilateral SLAC wrist deformity, Rheumatoid arthritis (RA), Right shoulder rotator cuff, and Spinal Stenosis with limited mobility uses rollator for ambulation. The patient had an X-RAY of the hand on 5/9/2024, which revealed Advanced degenerative arthritis changes in both wrists with bilateral SLAC wrist deformity—advanced degenerative arthritis changes of the carpometacarpal joint of the left thumb. MR Lumbar Spine: (8/2023)Status post fusion with satisfactory alignment. Equivocal minor loosening of screws at S1. No recurrent stenosis is seen. Who presented to the clinic with burning micturition, itching, and sore genitalia. She stated that she has been having burning, itching sensation and soreness around her vagina1 for the past three weeks. She was seen by an endocrinologist one week, who told her that the side effect of Farxiga (dapagliflozin) includes Vaginal yeast infections, which can trigger vaginal odor, white or yellowish vaginal discharge, and vaginal itching. However, she denied vaginal odor and vaginal discharge. She stated that symptoms have decreased since she stopped taking farxiga. The last dose was seven days ago. She denies cough, chest pain, SOB, fever, dizziness, palpitations, headache, or unintentional weight loss. She stated that she saw a neurologist two weeks ago for her back pain, who prescribed medical marijuana for pain management; she said that she only took it for three days, and the pain was only alleviated pain for a few hours, and pain usually returned. She stated that she stopped taking medical marijuana because she did not like how she was feeling after taking the medication; she noted that the medication increased her appetite and made her feel unwell. She also stated that she received an Injection of steroids in the B/L wrist, which did not help with the pain in the wrist. She rated her back, wrist, back, and shoulder pain as 5/10 intensity on the pain scale. The pain was described as sharp, intermittent, aggravated by movement, and alleviated by pain medication and rest.
Pertinent PMH: The patient is a 79-year-old African American female who presents to the office on 09/12/2024 with a complaint of increased burning, itching, and soreness in her vaginal for the past three weeks. She denies any recent travel or any sick contact at home or in church. The patient has PMH of HTN, NIDDM2, Hypothyroidism, HLD, osteoarthritis (OA) in both wrists with bilateral SLAC wrist deformity, Right shoulder rotator cuff, and Spinal Stenosis. She is retired, and she goes out every day to share religious pamphlets due to her Jehovah's Witness faith. The patient is currently taking Hydrocodone-acetaminophen 5-325 mg tablets, one tablet orally every q8hrs PRN for pain, Gabapentin 600 mg tablet, one tablet orally TID for pain, Ozempic 0.5 mg SubQ weekly, and Metformin HCL 1,000 mg tablet, one tablet orally BID for DM, Rosuvastatin calcium 5 mg tab one tablet orally for HLD, Amlodipine besylate 10 mg, one tab orally and metoprolol succinate ER 25 mg one tablet orally for HTN, and Synthroid 150 mcg tablet one tablet orally for hypothyroidism. Allergies: NKDA. Has seasonal allergies. The patient denies drug, tobacco, or alcohol use. Both parents have passed. The patient's mother had no significant medical hx and passed from old age at 95 years old, and the father had an hx of HTN and passed away at age 80 years. The Patient has two sisters who have medical hx of HTN and are still living. She is a widow whose husband passed away three years ago; she has three grown children who live in different states. Her last BM was this morning. She is up to date on all her vaccines. She has taken all three COVID-19 vaccines from Moderna, and a flu vaccine was given during this visit.
Family history:
- The patient's mother had no significant medical hx and passed from old age at 95 years old, and the father had an hx of HTN and passed away at age 80 years.
-The Patient has two sisters who have medical hx of HTN and are still living.
- she has three grown children who live in different states with no significant medical history
Social history:
-She is a widow and lives alone. Her husband passed away three years ago; she has a home health aide assistant that helps with activities of daily living;
