Diagnostic Reasoning Case Study Jennifer Hood University of Texas Arlington College of Nursing and Health Innovation Nursing 5333 Family Nursing I Kashiris Perryman, DNP, APRN, FNP-PC June 12, 2021

Diagnostic Reasoning Case Study Jennifer Hood University of Texas Arlington College of Nursing and Health Innovation Nursing 5333 Family Nursing I Kashiris Perryman, DNP, APRN, FNP-PC June 12, 2021 Soap Note S/ Identifying Information: Martha 26 yo female DOB July 12, 1995 Family Hx: Mother--DM (Alive) Father—COPD (Alive) Brother—No preexisting conditions (Living) Personal/Social Hx: Chief Complaint/RFE: College Graduate Currently employed as a schoolteacher Financially secure Lives alone in apartment Feels safe at home and in current relationship Heterosexual Monogamous relationship with boyfriend Denies smoking and drug abuse Socially drinks: 1-2 glasses of wine/weekend vaginal burning x 3 days Hx Present Illness: 26 yo female comes into clinic today in no acute distress. Reports vaginal burning for the last 3 days. Is sexually active and last sexual intercourse was one week ago. CURRENT HEALTH Medications: No Medications, vitamins, or herbal supplements Allergies: NKDA. Seasonal allergies in the Spring Last PE & Screenings: Last PAP 2016 (age 21): Negative Immunization Status: Has not received HPV vaccine LMP & Birth Control (if applicable) PMH Illnesses & Trauma: None Hospitalizations/Surgeries: tonsillectomy 2002 (age 7) OB Hx/Sexual Hx: Sexually active since age 15. Has had 2 relationships this past year. Last sexual intercourse: 1 week ago Emotional/Psy Hx: REVIEW OF SYSTEMS General Denies fever, chills, nausea, vomiting, and diarrhea Nutrition defer Skin/Hair/Nails defer HEENT defer HEAD – EYES— EARS-- NOSE— THROAT-- Breasts defer Respiratory defer CV/peripheral vascular defer GI defer GU Vaginal burning, dysuria, large amount of foul smelling vaginal discharge; first occurrence, dyspareunia. Denies use of vaginal sprays, douches, or powders or use of new soap, detergent, or clothing. Wears thong underwear MSK defer Psych defer Neuro defer Lymph/Heme/Endocrine defer O/ PE: T: 98.6 P: 64 R: 18 BP: 110/70 HT: 160 cm WT: 54.4 kg BMI: 21.25 General appears to be slightly anxious but pleasant and cooperative Skin defer Head defer EENT EYES-- EARS— NOSE-- THROAT— Neck defer Breasts/Chest defer Lungs RLL clear to all lung fields Heart/ peripvascular RRR, no murmurs auscultated Abdomen soft, no distension, nontender, no organomegaly Genitalia/Rectum vaginal mucosa moist and pink with mild edema. Copious discharge in introitus with foul odor. Cervix pink and friable. Chandler sign (-). pH mild alkalinity, wet prep shows trichomads Lymph no swelling or tenderness noted to inguinal LNs MSK defer Neuro defer Differential 1 Trichomoniasis Differential 2 Candida Vulvovaginitis (VVC) Differential 3 Bacterial Vaginosis (BV) Epidemiology (short synopsis) for each Who, Where, When -infection that is sexually transmitted and acquired by direct sexual contact (Schumann & Plasner, 2021) -can also live on surfaces for brief periods of time and transmit disease if person comes into contact (Hollier, 2021) -prevalence and incidence is higher in African regions and North America than in other parts of the world (Bouchemal, Bories, & Loiseau, 2017) -affects both men and women (Bouchemal, Bories, & Loiseau, 2017) -some strains carry their own viruses that increase inflammatory responses (Bouchemal, Bories, & Loiseau, 2017) -can be transmitted to fetus by mother (Bouchemal, Bories, & Loiseau, 2017) -most prevalent amongst women age 40-49 (Schumann & Plasner, 2021) -risk factors: hx of STD, multiple sex partner, contact with infected sex partner, not using barrier contraception during sex, IV drug abuser (Schumann, & Plasner, 2021) -responsible for 1/3 of all cases of vulvovaginitis in reproductive age women (Jeanmonod & Jeanmonod, 2021) -most common pathogen is Candida Albicans (Jeanmonod & Jeanmonod, 2021) -risk factors: estrogen use, elevated endogenous estrogen, DM, immunosuppressive state, antibiotic use— especially broad sprectrum antibiotics (Jeanmonod & Jeanmonod, 2021) -women that are in the reproductive years are more prone to VVC then any other age group (Goncalves, Ferreira, Alves, Henriques, Azeredo, & Silva, 2016) -most common cause of vaginal discharge and odor in women (Bagnall & Rizzolo, 2017) -lower rates of occurrence in women on oral contraceptives with the thought that the estrogen component “nurtures” the lactobacilli in the vagina (Bagnall & Rizzolo, 2017) -risk factors: black or hispanic ethnicity, frequent douching, smoking, multiple sex partners, not using a barrier method during sex (Bagnall & Rizzolo, 2017) -most common vaginal disorder worldwide (Goje & Munoz, 2017) Pertinent -pH 4.5 which would indicate -presents with vaginal -pH 4.5 (Goje & positives for each mild alkalinity (Goje & Munoz, 2017) -wet prep (+) for trichomads (Goje & Munoz, 2017) -foul “fishy” smelling discharge (Schumann & Plasner, 2017) - dyspareunia, dysuria, (Schumann & Plasner, 2017) burning, pain, and discharge (Willems, Ahmed, Liu, Xu, & Peters, 2020) Munoz, 2017) - foul “fishy’ odorous discharge (Phillippi & Danhausen, 2019) - c/o dysuria, dyspareunia (Kairys & Garg, 2020) Pertinent negatives for each -internal vaginal pruritis (Phillippi & Danhausen, 2019) -vaginal erythema (Phillippi & Danhausen, 2019) -pelvic pain (Schumann & Plasner, 2021) -post-coital bleeding (Phillippi & Danhausen, 2019) -white, cottage cheese- like clumpy discharge (Willems, Ahmed, Liu, Xu, & Peters, 2020) -pH 4.5 (Goje & Munoz, 2017) -(+) wet prep test will show hypae (Goje & Munoz, 2017) -(+) wet prep test will show clue cells, reduced or absent lactobacilli count (Goje & Munoz, 2017) Patho short summary for each -Parasitic protozoan with a total of five flagella, four which aid in giving it a twisting and wriggling movement (Bouchemal Bories, & Loiseau, 2017) -lives in the urogenital tract of the infected individual (Schumann & Plasner, 2021) -adheres to and damages the vaginal squamous epithelial cells by releasing cytotoxic proteins that destroy the individual’s epithelial lining of the GU tract (Schumann & Plasner, 2017) -adhesion of Candida to host’s vaginal mucosal lining is needed for colonization to occur and establish an infection (Gonclaves, Ferreira, Alves, Henriques, Azeredo, & Silva, 2016) -Candida can also adhere to medical device surfaces so that when a pelvic exam is performed, the woman is exposed to the -caused by an imbalance of naturally occurring vaginal flora. Normally, lactobacilli dominate normal vaginal flora but in BV, there is an overall decline in Lactobacilli. (Kairys & Garg, 2020) -With the declining number of Lactobacilli in the vagina, bacteria begin to adhere to the vaginal epithelium where they begin to proliferate (Phillippi & Danhausen, 2019)