miss professor

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<td bgcolor="#000000"line-height:100%;">   Miami Regional University   (Acct #3111)</td>

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<td width="50%">  Case ID #:

1332-20170609-007 </td>

Date of Service:

6/9/2017 </td>

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Student Information - Norona, Maria</td>

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Semester:</td>

Summer

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Course:</td>

MSN6050 Advanced Practice in Primary Care II

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Preceptor: </td>

BATISTA, JULIO

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Clinical Site:</td>

Julio Batista Ortiz Medical Center

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Setting Type:</td>

Underserved area/population

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Patient Demographics</td>

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Age:</td>

30 years

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Race:</td>

White, Non Hispanic

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Gender:</td>

Female

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Insurance:</td>

Private insurance

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Referral:</td>

No referral

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Clinical Information</td>

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Time with Patient:</td>

35 minutes</td>

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Consult with Preceptor:</td>

15 minutes</td>

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Type of Decision-Making:</td>

Low complexity

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Reason for Visit:</td>

Initial Visit

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Chief Complaint:</td>

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Encounter #:</td>

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</td>

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Type of HP:</td>

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Problem Focused

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Social Problems Addressed:</td>

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Safety Sexuality Prevention Nutrition/Exercise 

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Procedures/Skills (Observed/Assisted/Performed)</td>

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Physical Assessment - Physical Assessment (Perf) 

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ICD-10 Diagnosis Codes</td>

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#1 - 

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N39.0 - URINARY TRACT INFECTION, SITE NOT SPECIFIED

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#2 - 

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B37.3 - CANDIDIASIS OF VULVA AND VAGINA

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CPT Billing Codes</td>

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#1 - 

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99203 - OFFICE/OP VISIT, NEW PT, 3 KEY COMPONENTS: DETAILED HX; DETAILED EXAM; MED DECISION LOW COMPLEXITY

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#2 - 

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81000 - URINALYSIS, DIP STICK/TABLET REAGENT; NON-AUTOMATED W/MICROSCOPY

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#3 - 

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87086 - CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE

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#4 - 

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36415 - COLLECTION, VENOUS BLOOD, VENIPUNCTURE

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#5 - 

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2010F - VITAL SIGNS DOCUMENTED AND REVIEWED

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#6 - 

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4450F - SELF-CARE EDUCATION PROVIDED TO PATIENT

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Birth & Delivery</td>

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Medications</td>

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# OTC Drugs taken regularly:</td>

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2</td>

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# Prescriptions currently prescribed:</td>

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2</td>

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# New/Refilled Prescriptions This Visit:</td>

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0</td>

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Types of New/Refilled Prescriptions This Visit: 

Gynecology - Vaginal anti-infectives Infectious Diseases - Sulfonamides 

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Adherence Issues with Medications: 

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Other Questions About This Case</td>

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Patient's Primary Language:</td>

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English

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Smoking Assessment:</td>

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Never

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Advanced Directive:</td>

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<tr><td bgcolor='#FFFFFF' valign = 'top' width='50%'>Packs per day:</td><td bgcolor='#FFFFFF'>0</td></tr>

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Clinical Notes</td>

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CC: "I am having vaginal itching and pain in my lower abdomen." HPI:Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami . She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since a months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200 mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. PMH: Gerd take Protonix 40 mg PO Daily in the morning. Allergic to ASA. Toxic Habits. No smoke, alcoholic beverage only in social events. GH: G0.P0.,A0. LMP: Start today. Objective: Weight 140 lb Temp 97.7 BP 123/82 Height 5'4" Pulse 74 Resp 18 Physical examination: General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Skin Skin is normal color for ethnicity, warm, dry, clean and intact. No rashes or lesions noted. HEENT Head is normocephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra heart sounds. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal Abdomen flat; BS active in all 4 quadrants. Abdomen soft, suprapubic tender. No hepatosplenomegaly. Genitourinary Suprapubic tenderness noted. Skin color normal for ethnicity. Irritation noted at labia majora, minora, and perineum. No ulcerated lesions noted. Lymph nodes not palpable. Vagina pink and moist without lesions. Discharge minimal, thick, dark red, no odor. Cervix pink without lesions. No CMT. Uterus normal size, shape, and consistency. Lab Tests Urinalysis - blood noted (pt on menstrual period), but results negative for infection Urine culture testing unavailable Wet prep - inconclusive STD testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B & C No special test ordered. Assessment: UTI and Vulvovaginal Candidiasis secondary to presenting symptoms. Plan: Medication - Terconazole cream 1 vaginal application QHS for 7 days for Vulvovaginal Candidiasis; Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days for UTI . Education: The patient was instructed not to douche because doing so may upset the healthy balance of bacteria. She was also instructed to complete the entire dose of medication as prescribed even if symptoms resolve after a few doses and use a condom when having sex to protect herself from becoming reinfected. Follow-up - Pt will be contacted with results of STD studies. Return to clinic when finish the period for perform the pap=smear or if symptoms do not resolve with prescribed tx.

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