This study source was downloaded by 100000851646087 from CourseHero.com on 02-02-2023 02:26:09 GMT -06:00
https://www.coursehero.com/file/95851655/N5333-Diagnostic-Reasoning-STD-case-Study-Family-Final-F-2docx/1
STD DIAGNOSTIC REASONING CASE STUDY
Nursing 5333 Family Nursing 1 // Martha STD Diagnostic Reasoning Case Study
STD Diagnostic Reasoning Case Study
Elizabeth Khan
University of Texas at Arlington College of Nursing and Health
Innovations Nursing 5333 Family Nursing 1
Bethany McClean MSN, APRN, FNP- BC April 23, 2021 This study source was downloaded by 100000851646087 from CourseHero.com on 02-02-2023 02:26:09 GMT -06:00
https://www.coursehero.com/file/95851655/N5333-Diagnostic-Reasoning-STD-case-Study-Family-Final-F-2docx/STD Case Study
Subjective:
Martha is a 26-year-old female who reports vaginal burning for 3 days. She says that she can barely focus on other things because of the burning. She also reports a copious foul-smelling vaginal discharge.
Her last pap smear was at age 21 and was negative. She has not received the HPV vaccine series. Martha
denies previous episodes and states that she is otherwise healthy. She denies fever, chills, nausea, vomiting or diarrhea. She is sexually active and has been sexually active with males since age 15. She states that she has had 2 relationships in the past year. Last intercourse was last week. She admits to dyspareunia and burning with urination. She denies use of vaginal sprays, douches, or powders or the use of new soaps detergent or clothing. She wears a thong regularly.
Past Medical History:
Tonsillectomy at the age of 7.
Currently on no medications or herbal/vitamin supplements
Family History:
Mom with diabetes; Dad COPD; Brother healthy
Social History:
Martha is a college graduate and lives alone in an apartment. She feels safe and has a good relationship with her boyfriend. Martha works as a teacher and feels financially secure. She does not smoke and denies drug abuse. She drinks socially on the weekends with 1-2 glasses of wine.
NKDA
Allergies: Seasonal in spring
Objective
Vital signs: Martha is afebrile. Her B/P is 110/70. Pulse is 64 and regular. Respirations are 18. She is 5 feet 3 inches tall and weighs 120 lbs.
General: Martha is pleasant and cooperative but anxious about the visit
Cardiac: Regular rate and rhythm without murmurs
Respiratory: Lungs are clear
Abdomen: Soft, nontender, nondistended, and without organomegaly
Pelvic Exam: Inguinal lymph nodes are without swelling or tenderness; vaginal mucosa is moist, pink, and mildly swollen. There is a fishy odor; copious discharge in the introitus. The cervix is pink and friable. There is a negative chandelier sign. PH is mildly alkaline and wet prep indicates trichomads.
https://www.coursehero.com/file/95851655/N5333-Diagnostic-Reasoning-STD-case-Study-Family-Final-F-2docx/1
STD DIAGNOSTIC REASONING CASE STUDY
Nursing 5333 Family Nursing 1 // Martha STD Diagnostic Reasoning Case Study
STD Diagnostic Reasoning Case Study
Elizabeth Khan
University of Texas at Arlington College of Nursing and Health
Innovations Nursing 5333 Family Nursing 1
Bethany McClean MSN, APRN, FNP- BC April 23, 2021 This study source was downloaded by 100000851646087 from CourseHero.com on 02-02-2023 02:26:09 GMT -06:00
https://www.coursehero.com/file/95851655/N5333-Diagnostic-Reasoning-STD-case-Study-Family-Final-F-2docx/STD Case Study
Subjective:
Martha is a 26-year-old female who reports vaginal burning for 3 days. She says that she can barely focus on other things because of the burning. She also reports a copious foul-smelling vaginal discharge.
Her last pap smear was at age 21 and was negative. She has not received the HPV vaccine series. Martha
denies previous episodes and states that she is otherwise healthy. She denies fever, chills, nausea, vomiting or diarrhea. She is sexually active and has been sexually active with males since age 15. She states that she has had 2 relationships in the past year. Last intercourse was last week. She admits to dyspareunia and burning with urination. She denies use of vaginal sprays, douches, or powders or the use of new soaps detergent or clothing. She wears a thong regularly.
Past Medical History:
Tonsillectomy at the age of 7.
Currently on no medications or herbal/vitamin supplements
Family History:
Mom with diabetes; Dad COPD; Brother healthy
Social History:
Martha is a college graduate and lives alone in an apartment. She feels safe and has a good relationship with her boyfriend. Martha works as a teacher and feels financially secure. She does not smoke and denies drug abuse. She drinks socially on the weekends with 1-2 glasses of wine.
NKDA
Allergies: Seasonal in spring
Objective
Vital signs: Martha is afebrile. Her B/P is 110/70. Pulse is 64 and regular. Respirations are 18. She is 5 feet 3 inches tall and weighs 120 lbs.
General: Martha is pleasant and cooperative but anxious about the visit
Cardiac: Regular rate and rhythm without murmurs
Respiratory: Lungs are clear
Abdomen: Soft, nontender, nondistended, and without organomegaly
Pelvic Exam: Inguinal lymph nodes are without swelling or tenderness; vaginal mucosa is moist, pink, and mildly swollen. There is a fishy odor; copious discharge in the introitus. The cervix is pink and friable. There is a negative chandelier sign. PH is mildly alkaline and wet prep indicates trichomads.
