NR602 week 4 discussion Kayla’s Case Study

NR602 week 4 discussion Kayla’s Case Study

Week 4: Discussion Part Two. FURTHER DATA

Vital Signs: height: 155 centimeters weight: 71 kilograms, B/P:120/62, T: 99.2, HR: 90, Resp: 16, reg, non-labored, SpO2: 99%

General: Awake, alert, appropriate; well groomed; skin: warm, dry, intact. HEENT: Head normocephalic. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils 1/4 bil; neck supple w/o lymphadenopathy.

Breast Exam: large pendulous breasts bil. No nipple discharge. No nodules. Three small 2mm erythematous bullous lesions in a linear pattern noted at 9 o’clock on the right breast.

Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen, soft, with normoactive bowel sounds throughout.

Abdomen: Normoactive bowel sounds throughout; tenderness to palpation in the super-pubic area; no masses or organomegally

External Genitalia: Mons intact with normal hair distribution, labia majora, minora, clitoris intact, Bartholin’s and Skene’s glands. Intact. No piercings. No hymen. Skin to the labia majora and vulvar area whitish and thickened.

Vagina: Pink, moist, with rugae, no odor, tone good. No rectocele, cystocele, or discharge.

Cervix: pink with multi-parous patent os, no lesions, sl. anterior and freely mobile without tenderness.

Uterus: small, firm, midline, smooth, mobile, non-tender uterus. Adnexae: present, smooth, non-tender.

Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, negative for Questions Part Two:

What is the primary diagnosis for Kayla with rationale?

What is the differential diagnosis with rationale?

Plan for each primary diagnoses based on one current evidence-based guidelines.

Include the following:

Further diagnostic work-up not included above

Medications

Referrals

Conservative measures

Patient education

Follow-up plan

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Week 4: Discussion Part Two

In the presented case, further data about the patient’s condition is provided, including vital signs and physical examination findings. The patient, named Kayla, is assessed through various aspects of her health.

Vital Signs:
– Height: 155 centimeters
– Weight: 71 kilograms
– Blood Pressure: 120/62 mmHg
– Temperature: 99.2°F
– Heart Rate: 90 beats per minute
– Respiratory Rate: 16 breaths per minute, regular and non-labored
– Oxygen Saturation (SpO2): 99%

General:
– Awake, alert, appropriate behavior
– Well groomed
– Skin: Warm, dry, intact

HEENT:
– Head: Normocephalic
– Conjunctiva: Clear, non-icteric
– Pupils: PERRLA (Pupils Equal, Round, Reactive to Light, Accommodation)
– Extraocular Movements (EOM’s): Intact
– Tympanic Membranes: Intact, unremarkable
– Nares: Patent, unremarkable bilaterally
– Pharynx: Unremarkable
– Tonsils: 1/4 bilaterally
– Neck: Supple, without lymphadenopathy

Breast Exam:
– Large pendulous breasts bilaterally
– No nipple discharge
– No nodules
– Three small 2mm erythematous bullous lesions in a linear pattern noted at 9 o’clock on the right breast

Cardiopulmonary:
– Heart: Regular rate and rhythm without murmur
– Lungs: Clear to auscultation throughout
– Respirations: Even and unlabored
– Abdomen: Soft, with normoactive bowel sounds throughout

Abdomen:
– Normoactive bowel sounds throughout
– Tenderness to palpation in the suprapubic area
– No masses or organomegaly

External Genitalia:
– Mons: Intact with normal hair distribution
– Labia majora, minora, clitoris, Bartholin’s, and Skene’s glands: Intact
– No piercings
– No hymen
– Skin to the labia majora and vulvar area whitish and thickened

Vagina:
– Pink, moist, with rugae
– No odor
– Good tone
– No rectocele, cystocele, or discharge

Cervix:
– Pink with multi-parous patent os
– No lesions
– Slightly anterior and freely mobile without tenderness

Uterus:
– Small, firm, midline, smooth, mobile, non-tender uterus

Adnexae:
– Present, smooth, non-tender

Urinalysis in the office:
– Cloudy amber yellow urine
– Specific Gravity: 1.010
– Negative for infections

Questions Part Two:

Primary Diagnosis for Kayla:
The primary diagnosis for Kayla could be “Urinary Tract Infection (UTI)” due to her urinary symptoms (frequent urination) and the cloudy amber yellow urine on urinalysis.

Differential Diagnosis:
1. Urinary Tract Infection (UTI)
2. Vulvovaginitis
3. Urethritis
4. Genital Herpes

Plan:

Urinary Tract Infection (UTI):
– Further Diagnostic Work-Up: Urine culture and sensitivity test
– Medications: Antibiotics based on urine culture results
– Referrals: None necessary
– Conservative Measures: Hydration, avoid irritants
– Patient Education: Importance of completing prescribed antibiotics, hygiene
– Follow-Up Plan: Follow up in 3 days to assess response to antibiotics

Vulvovaginitis:
– Further Diagnostic Work-Up: Vaginal swab for culture and wet mount
– Medications: Antifungal or antibacterial treatment based on culture results
– Referrals: Gynecologist if needed
– Conservative Measures: Avoid irritants, wear cotton underwear
– Patient Education: Importance of hygiene, avoiding irritants
– Follow-Up Plan: Follow up in 7 days to assess response to treatment

Urethritis:
– Further Diagnostic Work-Up: Urine analysis and culture
– Medications: Antibiotics based on culture results
– Referrals: None necessary
– Conservative Measures: Hydration, avoid irritants
– Patient Education: Importance of completing antibiotics, hygiene
– Follow-Up Plan: Follow up in 3 days to assess response to antibiotics

Genital Herpes:
– Further Diagnostic Work-Up: Viral culture or PCR test
– Medications: Antiviral medications for symptomatic relief
– Referrals: Gynecologist for further evaluation
– Conservative Measures: Pain relief measures
– Patient Education: Importance of safe sex practices, managing outbreaks
– Follow-Up Plan: Follow up in 7 days to assess response to treatment

It is important to note that the above plan is based on hypothetical scenarios and should be tailored to the patient’s actual condition and preferences. Consultation with a healthcare professional is advised for accurate diagnosis and treatment.