NR 603 Week 5 Part 1.
S
CC: STI Check
HPI- B.S. 29 y/o, Caucasian female who presents with vaginal irritation, itching, burning, and discharge for 3 days. Pain is described as intermittent dull/burning to vagina that is worse with urination, rates as 6/10. Nothing relieves the pain as nothin...
caucasian female who presents with vaginal irritation
and discharge for 3 days pain is described as
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Chamberlain College Nursing
NR 603
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NR 603 Week 5 Part 1.
S
CC: STI Check
HPI- B.S. 29 y/o, Caucasian female who presents with vaginal irritation, itching, burning, and
discharge for 3 days. Pain is described as intermittent dull/burning to vagina that is worse with
urination, rates as 6/10. Nothing relieves the pain as nothing has been tried at home. Patient
reports vaginal discharge that is thick and clear to yellow in color. She admits to having multiple
unprotected heterosexual (vaginal sex only) encounters with 2 men within the last month. Denies
history of previous STDs. Uses condoms most of the time but there have been some encounters
which she did not use a condom. Currently not on any form of birth control. Patient has no
significant medical or surgical history. G1P1, last PAP exam was about 2 years ago and was
normal. Immunizations are up to date, but she has not received the HPV vaccine. Patient has no
past medical or surgical history, no known drug allergies and does not take any home
medications or OTC preparations regularly. Patient is single, employed as a customer service
representative for a local company and lives in an apartment with her 6 y/o daughter. Denies
smoking history, drinks alcohol socially on weekends, and denies illicit drug use.
ROS:
Constitutional: denies fatigue, fever, chills, and weight loss/gain.
HEENT: denies nasal discharge, sneezing, or tearing.
CV: denies chest pain, dizziness, or shortness of breath.
Resp: denies cough, shortness of breath, or congestion.
GI: +lower abdominal pain. Denies nausea or vomiting.
GU: LMP 7/25/2018. First period at age 13 with regular monthly cycles about every 30 days,
admits to unprotected sex with 2 sexual partners. denies dysuria, urgency, frequency, blood
in urine, pain with urination, +vaginal discharge, itching, burning, and dyspareunia.
MUSCULOSKELETAL: denies muscle aches or weakness.
SKIN: denies lesions or rashes.
NEURO: denies numbness, tingling, or dizziness.
PSYCH: denies anxiety, depression, or SI/HI.
ENDO: denies heat or cold intolerance.
LYMPH: denies bleeding, bruising, or infection.
ALLERGIC: denies any allergies.
O
, PE:
General: This is a 29 y/o female that is afebrile, with normal vital signs BP: 104/68 HR: 76
RR: 14 T: 98.1 O2: 98% RA Ht: 65 inches Wt: 132 pounds, BMI 20.53. Appears in no acute
distress. She is alert and oriented x 3 with normal mood and affect.
HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. No
sinus tenderness. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears:
Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized.
Nose: Nasal mucosa pink. No septal deviation. Neck: Supple. Full ROM. No lymphadenopathy,
thyromegaly, or nodules. Oral mucosa pink and moist. Pharynx pink. Teeth are in good repair.
Chest/Lungs: Chest wall symmetrical, no use of accessory muscles, breath sound clear to
auscultation bilaterally in all fields.
CV: S1, S2 noted with regular rate and rhythm. No clicks, rubs, or murmurs noted. Capillary
refill less than 3 seconds. Pulses 3+ in all extremities. No edema noted.
Abdomen: Abdomen is soft and nondistended without lesions or discoloration with normal
bowel sounds present in all 4 quadrants. Tenderness noted upon palpation in right and left lower
quadrant. No guarding or hepatosplenomegaly.
Genital: External genitalia normal w/o lesions. Vulva erythematous, excoriated, and swollen.
Vaginal mucosa pink with moderate amount of thick white discharge without odor present in
vaginal canal. Cervix intact without lesions or tenderness. Uterus midline, mobile, and non
tender. No adnexal masses palpable.
Specimens collected via swab for GC/Chlamydia and Trichomoniasis
Musculoskeletal: ROM intact in all extremities.
Neurologic: Alert and oriented with normal affect and mood. Speech clear and organized;
answers questions appropriately. Gait steady; able to move all extremities well. Sensations
intact.
Skin: Skin pink, warm, and dry with good turgor. No rashes, lesions, or ulcers.
Associated Risk Factors
Unprotected sex with one or more partners of unknown status is a major contributing factor of
contracting an STI. In this case BS admits to having multiple unprotected sexual encounters
with more than one person of unknown status. Social, economic, and behavioral factors also
contribute to increased risk. Racial and ethnic disparities are among risk factors and has shown
that African Americans and Hispanics have the highest STD rates. These rates are thought to be
related to lack of access to care, social stigma, poverty, and substance abuse (U. S. Department
of Health and Human Services [USDHHS], 2014). BS has inconsistent use of condoms and
alcohol use which increases her risk of contracting an STD.
Differential Diagnosis
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