clinical diagnostic paperredgurl88
CC: "I have itchy white discharge” HPI: Patient is a 32 African American female who reports having increased vaginal itching and discharge times 2 days. She states that her vagina feels irritated and that the itch is progressively getting worst. She reports a thick white cottage cheese discharge is present. She reports that she used a Monistat 3 day 6 days ago but hasn't had any relief. She states that the pain is worst after sex. PMH: Patient denies having any past medical history. She denies any past traumas or hospitalizations. PSH: Patient denies having a history of trauma. Patient denies having any surgical history. Allergies: Patient denies having allergies to latex, food or any medications. Medications: Patient reports she is currently on no medications. Social history: Patient reports that her entire family lives nearby. She states that she lives in a two-bedroom apartment alone. States that she drinks 3 glasses of 8oz glasses of wine with friends twice a week. Denies recreational drug use. Denies tobacco use. Reports that she is single. She denies having any new sex partners during the last 3 years. She states that she drinks 1 8oz cups of coffee daily. She reports that she has worked as a real estate agent for the last 2years. Reports no job-related stressors.
Family History: Patient reports that her mother is a live and has a medical history of that she was diagnosed with anxiety and depression at the age of 35. She states her father has a medical history of depression which he was diagnosed with at age 45. She reports her maternal grandmother had a history of COPD and CHF. She reports her maternal grandmother died from complications of chronic kidney disease at the age of 80. She reports that her maternal grandfather had a medical history of hypertension, she reports he is still alive at 88. Patient reports her paternal grandmother has a medical history of CHF and diabetes mellitus type 2. She reports her paternal grandmother is still alive at 85 but has dementia She states paternal grandfather had a medical history of COPD and CHF, she reports he died at age 85 from complications of diabetes mellitus type 2. She has two older sister who both have no medical history. Health Promotion/Maintenace: Patient reports she had a flu shot in September 2017 in a private doctor's office. Reports she had a TDAP booster in 2014. Based on the patients age USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. Reports she had a std screen 2 years ago. She reports that she has never had an abnormal pap smear. She states STD screen was negative. Reports she had a pap 4 years ago. She reports she does monthly self-breast exams at home. She reports that she eats 2 times daily. Reports she eats well balanced nutritious meals for each meal. She reportedly drinks approximately 30oz of water a day. General: Patient reports having, fever, chills, and malaise Skin: Patient denies any open wounds, bruises, sores, or any areas of breakdown on skin. HEENT: Patient denies abnormal growths on head. Patient denies having a hard time hearing. She denies ear pain. Patient denies tinnitus. She reports having a sore throat. She reports having nasal congestion. Patient reports headache. CV: Patient denies having palpations, chest pain, or edema. She denies having any cardiac history. Lungs: Patient denies having a cough. She denies having shortness of breath. GI: Patient denies being constipated. Patient denies abdominal pain or cramping. She denies and changes in bowel movement. She reports a decreased appetite. GU: Patient denies any changes to color of urine. She denies having urinary retention. She denies having urgency or frequency. Patient denies having urinary incontinence. Patient reports vaginal itching. Reports having a white vaginal discharge that is think like cottage cheese. MSK: Patient denies having trouble ambulating. Patient denies having joint pain. Patient reports having full range of motion in all extremities. Endo: Patient denies any episodes of hypoglycemia. Denies being intolerant to cold. Denies intolerant to heat. Denies a history of thyroid disease. Reports occasional episodes of hyperglycemia. Psych: Patient denies auditory or visual hallucinations. Denies tactile hallucinations. Denies suicidal or homicidal thoughts. Denies feeling paranoid. Reports insomnia. Reports feeling anxious for a year. Reports having racing thoughts. Neuro: Patient denies loss of memory. Denies blurred or double vision. Patient denies dizziness. Denies numbness and tingling in extremities. thoughts. Denies feeling paranoid. OBJECTIVE Gen: Patient is well nourished. She is alert, oriented, calm, and cooperative. She is appropriately dressed for the season. Patient has a fever. VS: BP=125/67 Pulse= 80 RR= 18 O2=97% Temperature=98.7 degrees Fahrenheit Height= 5 ft 1inches Weight = 178lbs BMI= 33.6 (Obese) SKIN: Upon inspection skin is intact with no obvious open wounds or bruises noted. Upon palpation skin the skin is warm and dry. HEENT: Inspection of the head reveals head is norm cephalic. Hair is thick and evenly distributed across head. No deviated septum noted. CV: Heart S1 and S2 noted, RRR, no murmurs or additional sounds noted. Lungs: Lungs auscultated breath sounds present and clear in all lobes. No wheezing, rhonchi, or stridor noted. ABD: No abdominal tenderness noted upon palpation. Bowel sounds present in all quadrants on auscultation. GU: On examination patient has curdy white discharge. Mucosa appears to be inflamed. Mucosa redness noted. PV: No hyperpigmentation noted in extremities. No edema noted. MSK: Patient has full range of movement in all extremities. Neuro: Gait is steady. CN II-XI grossly intact, No ataxia noted. Strength is equal in upper and lower bilateral extremities. No signs of weakness noted. Speech is clear. She is alert and oriented. Memory is intact. Psych: No delusions noted. No self-conversing noted. Mood is appropriate. She is calm and cooperative. Diagnostics: For recurrent infection check HIV antibodies. Check FBS, HbA1C. Rule out hematologic malignancy or solid organ malignancy (Ferri, 2015). Diagnosis: B37.3 Vulvovaginal Candidiasis CPT Code: 99214"office or other outpatient visit for the evaluation and management of an established patient Plan Diagnostic: Obtain scraping from the vagina. The presences of hyphae/pseudohyphae or budding yeast cells on a wet smear as well as confirmation by culture is recommended (Ferri, 2015) KOH smears may be helpful. Therapeutics: One single dose of oral fluconazole or Topical antifungal agent. For chronic or recurrent cases treat with fluconazole 150mg qod times 3 doses and then 150mg / wk for 6 months (Ferri, 2015). Education: Educate patient on the importance of maintaining a dry environment by wearing cotton underwear (Ferri, 2015). Educate patient on the importance of decrease antibiotic use (Ferri, 2015) Educate patient on the importance of daily probiotic use. Studies suggest that eating eight ounces of yogurt with "live cultures" daily or taking Lactobacillus acidophilus capsules can help prevent infection (Ferri, 2015). Encourage patient not to use douches (Ferri, 2015). Consultation: Possible referral to infectious disease specialist if no etiology found in recurrent infection (Ferri, 2015). Reference Ferri, F. (2015). Candidiasis. Ferri's clinical advisor 2016: 5 books in 1. Amsterdam: Elsevier. U.S. Preventive Services Task Force (September 2018). USPSTF A and B Recommendations: Cervical cancer screening: Adults Retrieved from U.S. Preventive Services Task Force: https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations