please see attached document for assignment details. 

CDC Sexually Transmitted Diseases Case Study.

Read the patient case study below

General:

The patient is a young seventeen-year-old female who came to the clinic with complaint of abdominal pain.

Chief Complaint:

Kim reports “I’ve been having pain in my stomach for several weeks.” She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.

Reliability and Source of History:

The patient is alert and oriented and able to answer most of the questions.

Source & Reliability of History:

O – “I have been having pain in my stomach for several weeks now.” she stated that the pain has lasted for two weeks without any relief.

L – Both sides of her lower stomach

D – The patient reported that she has been having this bilateral lower stomach pain for the last two weeks, However, the symptoms got worse since the pain started ago.

C – She stated that since the onset of the pain, her pain has remained constant without any relieve and aggravating factor. The pain is firm regardless of the time or day or event. She further stated that her symptoms get worse. The patient states that she is unaware of what caused the pain or how the pain started; however, she stated that taking pills could relieve her stomach pain and stop her bleeding

A – She stated that the pain remains constant. She also stated that she is unaware of what caused the pain or how the pain started.

R – She stated that the pain remains steady and does not go away or radiate to other areas.

T- she reported feeling uncomfortable doing her regular shores due to the pain.

Past Medical history: 

Patient is asthmatic; however, her asthma is under control. She knows known history of any other condition or never been hospitalized.

Family History: 

She is the second in a family of four who are all alive and healthy. There is no history of any chronic condition in the family.

Social History:

Patient is a regularly active young woman; she is single and does moderately active exercise. However, she stated that her daily activity and chores has recently reduced due to her recent symptoms of pain. She also stated to have no appetite secondary to her recent pain. She also stated that her stress level may be related with her college. She has no history of alcohol, smoking, or had never smoked in her life. She has not used any illicit drug. She is very safe with rules like using her seatbelt and sunscreen. She also stated to have a smoke alarm in her room, overly cautious. She has never been pregnant or been diagnosed with any other sexually transmitted diseases. She denies having multiple sex partner or being on contraceptive recently.

Medications: 

The patient is on inhaler (albuterol) which is a short-acting beta-agonist. She takes this to relieve her asthma condition.

Allergies: 

NKDA

Review of System

Vital Signs:

Patient blood pressure was 100/60, Resp: 18, Pulse 100, Temp: 100.3, Oxygen saturation 97%. The patient height is 5 ft; 3inches, her weight was 135 Ibs.

General: The patient is alert and oriented, she appears to be relaxed and without any distress noted except being worried about the pain which she states “if I take a pill, that should relieve my pain and bleeding.”( Kim, 2020)

Skin: Patient denies any skin issues, rashes, or itching. The patient reports the use of sunscreen whenever needed, especially when outside in the sun.

Hair/nails: Patient reports no change in her nails or hair loss.

Head: Patient denies any headaches, or any history of head injury, or dizziness

Eyes: Patient stated to have a clear vision. denies any pain, or dryness, stated She doesn’t wear any glasses.

Ears: Patient denies any ear problems, no hearing aids with hearing, denies any pain, vertigo, tinnitus, discharge, or any history of infections

Nose and sinus: patient denies having any sinus infection during the assessment.

Mouth and throat: The patient denied any mouth problems or infection, denies any bleeding from the gums, no sore throat.

Neck: The patient denies any pain or stiffness.

Breasts: The patient denies any breast pain

Respiratory system: The patient denies any trouble breathing, coughing, or talking. Denies any history of lung disorder

Cardiovascular: the patient reports lower abdominal pain.

Peripheral Vascular: Patient denies any leg cramps, varicose veins, denies any history of blood clots, swelling, coldness, or numbness

Gastrointestinal: she denies any changes in her diet. She also stated that the pain did not start with food nor does she get relieve from food.

Urinary: Patient denies any difficulty during urination, denies any burning sensation, nocturia, polyuria, hesitancy, straining

Genitals: Patient denials any Genital issue/Past or Present STD.

Sexual health: The patient reports Normal sexual habits. No Multiple partners. She’s not married.

Musculoskeletal system: Patient denies any muscle or joint pains, stiffness, arthritis, gout, back pain, swelling, redness, stiffness, ROM

Neuro: Patient stated to have no dizziness, blackouts, seizures, weakness, paralysis, numbness, tingling, tremors in her extremities.

Psyche: The patient denies any sign of depression, nervousness, anxiety, or abnormal mood changes

Hematologic: The patient reported slight vaginal bleeding

Endocrine: The patient denies any history of diabetes diagnosis or issues in her family.

Functional Assessment:

Immunization:

Her immunization is up to date

Activity/Exercise
:

The patient reports she exercise frequently however she has not been able to do that due to her stomach pain.

Sleep/Rest
:

The patient reports not awakening at night, regardless of her symptoms.

Constitutional:

The patient Denies fever, chills. However, her temp was 100.3

Cardiovascular:

lower stomach pain. No complaint of chest pain.

Neurological
:

Denies slurred speech; the patient was able to communicate clearly, alert, oriented x

Nutrition
:

The patient nutrition seems regular.

Work:

College Student

Spirituality:

Parents were both Christian

Safety Concerns:

The patient report feeling worried about her college, however no other pain.

Psycho/Social history
: The patient stated she never smoke in her life, she denies use of any other drug use, EtOH, drugs, smoking, vaping. The patient denies any suicidal ideation or depression.

ASSIGNMENT REQUIRED
.

You will then formulate your differential diagnoses list, develop a plan of care, and submit a written clinic note documenting your care of this patient. Your differential diagnoses list should consist of 4 diagnoses, including 1 of which is your final diagnosis.

Please briefly describe your rationale and reasoning for why you would include or rule out a diagnosis in your working diagnosis list. What information from the subjective or physical examination is indicative of that diagnosis? Provide 6 research nursing and medical references for your rationale.

This paper should be 10 to 12 pages long.

________________________________________________________________________

Hint 1 (Patient primary diagnoses is pelvic inflammatory disease) other secondary diagnoses are anemia,

Hint 2 (patient treatment plan which should include the up to date a Combination of antibiotics to treat—- C.Trachomatis, N.Gonorrhoeae, Vaginal anaerobes and enteric gram negative rods.

Hint 3—this are the labs that you should order for the patient.

1. Hematologic/37/peripheral blood smear

2. Immunology /43 MHAT (Micro-hemagglutination Treponema)

3. Immunology/69/VDRL, Blood

4. Blood H-Z /09/iron, fe

5. Blood H-Z/10/Iron-binding capacity (TIBC)

6. Blood H-Z/01/Hepatitis panel:HBs, HBCcAG, HA, antiHBS, antiHA, antiHBc

7. Blood H-Z/12/Lactic Dehydrogenase (LDH)

8. Blood A-G/13/ALT(SGPT)

9. Blood A-G/12/Lactic Dehydrogenase (LDH)

10. Other/40/Laparoscopy

11. Urea breath test (Non-invasive

12. Hematologic complete blood count with differential CBC/Diff

13. Urine—-Hydroxycorticosteroids

14. Urine—-Urinalysis, Routine (UA)

15. Ultrasound—-Pelvis

16. Urine—-Human Chorionic Gonadotropin (pregnancy test, routine or equivalent)

17. Ultrasound—–Trans-Vaginal Ultrasound or equivalent

18. Microbiology—Chlamydia Culture

Required

1. Collaborative –Gynecologist /obstetrician (because a laparoscopy may be necessary).

2. Counseling —individual

3. Antimicrobial—-Antibacterial—-center for disease control should be followed.

4. Procedure—insert IV

5. Nursing Care—intravenous fluids

Treatment

1. Combination of antibiotics —-against C.Trachomatis, N.Gonorrhea, Vaginal anaerobes and enteric gram negative rods.

2. Intravenous Fluids —should be administered because patient is severe ill, She has fever

3. She will need to be Npo —just incase abdominal surgery is needed/ any patient in whom surgery or laparoscopy may be required for diagnosis of treatment so patient should be NPO until the question is resolved.

4. Narcotic Analgesic —needed for pain control once the diagnosed as been established.

5. Abstinence—-is the recommended form of contraception for adolescents. However oral or intramuscular contraceptives can be prescribed in addition to barrier methods if requested by the patient.

Recommended:

1. Diet—Npo

2. Endocrine—Contraceptives

3. Education—disease process/ counseling about STD

4. Education—preventative health

5. Activity—-Active range of motion or equivalent

6. Bed Rest—-is recommended in this patient to assist with pain control and prevent worsening of symptoms.

1. Ultrasound—pelvis

2. Urine—human chorionic gonadotropin (pregnancy test)

Follow-up

· A follow-up visit to monitor the abdominal and genital exam findings is necessary to assess the response to therapy

· Abdominal and Bimanual examinations should be done in follow-up to assess this patient’s response to therapy

· A follow up ultrasound may be indicated to ensure the disease process has completely resolved.

· Any adverse reaction to medication is vital and important