CASE STUDY #2 of 3 Suzy Jones is an 18-year-old college student who presents to the...
CASE STUDY #2
of 3
Suzy Jones is an 18-year-old college student who presents to the
Student Health Center seeking advice.
- White female college student
· Seeking advice about contraception and a current problem "down there" about a slight discharge.
· Shy talking about her sexual practices
· Has never had a pelvic exam
· Has had 2 sex partners in past 4 months
· Does not use condoms or any other contraceptives
· Her periods have been regular, but she has recently noted some spotting between
periods. Last menstrual period was 4 weeks ago.
· Denies dysuria, genital lesions, or sores, but does mention occasional vaginal itching.
Physical Exam
· Vital signs: blood pressure 118/68, pulse 74, respiration 18,
temperature 37.1° C
· Breast, thyroid, and abdominal exam within normal limits
· The pelvic exam reveals normal vulva, and vagina.
· The cervix appears inflamed, bleeds easily, with a purulent
discharge coming from
the cervical os. A slight amount of vaginal discharge is
noted.
· The bi-manual exam is normal without cervical pain, uterine or
adnexal tenderness.
Suzy Jones' cervix as revealed during pelvic exam
Questions
1. Based on Suzy’s history and physical exam, what do you
suspect?
2. Which laboratory tests should be ordered or performed?
3. What is the appropriate treatment at the initial visit?
Laboratory
Results
The test results are back from the laboratory for Suzy Jones:
· Serological test for syphilis - negative
· Serological test for Neisseria gonorrhea – negative
- Direct Unstained Wet mount – pH 4.2, no abnormal epithelial cells, trichomonas, or excessive bacteria noted. But numerous white blood cells are present.
- KOH (potassium hydroxide) wet mount screening for Candida albicans yeast – negative
- HIV antibody test – negative
- Pregnancy test – negative
Suzy is coming in later today to discuss her lab results. What are you going to tell her? After reviewing these results, are there any additional laboratory tests you believe are appropriate to look for other pathogens?
Homework Answers
1.The symptoms like vaginal itching ,spotting between periods and slight discharge indicates cervicitis
2.The laboratory tests which has to be ordered are
- Vaginal or cervical sample or swab to rule out ths type of infection
- CBC for elevated wbc
- Cervical culture
- Others:Herpes,HPV
3.The appropriate treatment are
Antibiotics like axithromycin and doxycycline are best to treat it.
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CASE STUDY #2
of 3
Suzy Jones is an 18-year-old college student who presents to the...
Suzy Jones is an 18-year-old college student who presents to the Student Health Center seeking advice....
Suzy Jones is an 18-year-old college student who presents to the Student Health Center seeking advice. • White female college student - Seeking advice about contraception and a current problem down there about a slight discharge - Shy talking about her sexual practices - Has never had a pelvic exam - Has had 2 sex partners in past 4 months - Does not use condoms or any other contraceptives Her periods have been regular, but she has recently noted some...
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Suzy Jones is an 18-year-old college student who presents to the Student Health Center seeking advice. • White female college student - Seeking advice about contraception and a current problem down there about a slight discharge - Shy talking about her sexual practices - Has never had a pelvic exam - Has had 2 sex partners in past 4 months - Does not use condoms or any other contraceptives Her periods have been regular, but she has recently noted some...
Case Study #1
(1 of 3)
V.Q., a 20-year old
woman with no denies any previous history of Urinary Tract
Infection, complains of burning on urination, frequent urination of
a small amount, and bladder pain. She has no fever or pelvic area
tenderness. A
clean-catch midstream urine sample shows Gram negative rods on Gram
stain. A culture and sensitivity test are ordered. Our patient is
presumed to have a lower UTI.
Question #1
What are some goals of the treatment...
An 18 year old girl presents to her pediatrician with her mother for her pre- college check-up. She has no past medical history. After her mother leaves the room for the social history component, the girl admits to having sex with her boyfriend for the first time two weeks ago and complains of a yellow green malodorous vaginal discharge that started a week ago. She endorses mild pelvic pain. A pelvic exam is performed and mild cervical tenderness is noted....
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Question 11 3 pts Case study matching question: Tanya is a 24-year-old single female who presented at her HMO with complaints of a smelly, yellow vaginal discharge and slight dysuria for one week. She denies vulvar itching, pelvic pain, or fever. She has had 2 sex partners over the past 6 months-did not use condoms with these partners-or oral contraceptives for birth control. No history of sexually transmitted diseases, except for trichomoniasis one year ago. Vital signs: blood pressure 112/78,...
Module 6 Teena Kissee Case Study I What are the potential ICD-10 codes in this case? 1. a. 2. How can the NP determine if the patient v/s an established patient at the clinic? 3. What components of care will be used for reimbursement decisions for Ms. Ward? 4. What type of physical examination level best fits what was performed on Ms. Ward? 5. If you were coding the list for Ms. Ward, how would you determine what decision-making level...
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