Centers for Disease Control and Prevention, Assessment Example

Introduction to Patient

A 35 year-old white female nulligravida is five feet tall and is morbidly obese at a weight of 325 pounds. She is experiencing several symptoms requiring further evaluation and diagnostics as appropriate in order to begin a treatment plan as soon as possible. The patient is currently single but has had one sexual partner for the past two years. She currently uses an IUD to prevent pregnancy, but she and her partner do not consistently use condoms.

Subjective Data

Chief Complaint: Vaginal discharge with odor and painful urination

History of Present Illness: Ms. C.D. is a 35 year-old single white female who presents with a greenish vaginal discharge with odor and painful urination, which she has had for the past ten days. She also has intermittent periods of itching and burning that have been bothering her, mostly at night. She has been with the same sexual partner for the past two years. C.D. noted that her symptoms began ten days ago and she was surprised because she had never had these exact symptoms before. She has not had sexual intercourse over the past six days because it is too uncomfortable, and the odor, although slight, is making her embarrassed. Therefore, she is facing a difficult set of symptoms that require further evaluation. She denies any other symptoms at this time and has been feeling well for the past few months. She even indicated that she is looking into improving her diet and exercise regimen in order to lose weight and to feel better about herself.

Medications

Advil OTC for occasional headaches; Zyrtec for allergies; Prilosec OTC as needed for GERD

Allergies

Cat hair/dander

Past Medical History

C.D. has been overweight since she was a child. She grew up in a loving household; however, her parents did not pay much attention to diet and exercise. Her mother often cooked large amounts of meat and high carb meals that included potatoes and pasta. As C.D. grew older and went off to college, she did not pay much attention to her diet but she began to improve her exercise somewhat by walking around campus on a daily basis. However, she continued to gain weight. She consumes fast food products intermittently and has only recently begun to be concerned about her weight because her self-confidence is low and her GERD has been challenging to deal with and she has been experiencing frequent bouts of acid reflux. However, she continues to consume spicy foods on a regular basis that have made it difficult to get past these events.

Past Surgical History

C.D. reported that her only surgery to date was for a tonsillectomy at age 12. She was hospitalized, treated, and released the same day.

Personal Social History

C.D. is highly educated. After high school graduation, she attended college and earned her Bachelor’s Degree in Psychology. She then attended graduate school and earned her MBA in 2008. She is currently employed full time as a department manager at a local university and is responsible for budgeting and operations management.

C.D. has become somewhat of a homebody as of late because she is saving to purchase a home nearby. However, she was a frequent partier in her 20s and into her early 30s and consumed alcohol in social settings on a regular basis. Her parents remain married and have been so for 45 years and she has three older siblings, whom she is close to and communicates with regularly. She also has two nieces and three nephews, who she likes to spoil on a regular basis. Her friendships are also strong and since she notes that she does not like much drama in her life, she gets along well with most people, including her coworkers.

Family History

Her mother is overweight, hypertensive and diabetic, the former of which is controlled by medication and the latter of which is controlled via insulin injection twice daily. Her mother is beginning to experience mild diabetic neuropathy in her feet and attends a foot clinic regularly. Her father is slightly overweight and is currently in remission for prostate cancer and has hypertension treated with medication. All of her siblings are generally in good health.  Maternal grandparents are deceased with deaths from heart attack (grandmother age 82, grandfather age 84), stroke (grandfather age 73), and breast cancer (grandmother age 68).

Immunizations

C.D. obtained all required vaccinations as a child and currently has health insurance. She received a tetanus booster in 2012 and receives the influenza vaccine annually, along with a TB test required by her employer.

Review of Systems   

General: Morbidly obese, no recent changes in weight, no signs of weakness, fever, or fatigue; mild anxiety resulting from weight and lack of self-confidence

Skin: The patient does not present with eczema, itching, sores, or discoloration; hands and feet appear to be dry and heels have mild cracking

Eyes: Had a vision exam in 2013 and began wearing prescription progressive lenses, primarily for reading. She is farsighted with 20/20 far vision. She also uses her glasses to drive at night because of glare issues.

Ears: Occasional signs of hearing blockage attributed to allergies and Eustachian tube dysfunction. Often feels the need to pop her ears to improve her hearing, even several times per day when hearing appears to be muffled.

Nose: Patient has a minor deviated septum that appears to contribute to her nasal congestion and allergic tendencies that occur frequently. She denies any nose bleeding.

Throat: Denies any current tenderness in the throat, hoarseness, bleeding in the gums, swelling, and pain of any kind.

Neck: C.D. denies any type of pain or numbness, and no abnormalities have been reported.

Respiratory: The patient has occasional shortness of breath after walking many flights of stairs, but no other evidence of shortness of breath, rales, or wheezing.
Cardiovascular: Patient denies any type of palpitations, pain in the chest, and only experiences difficulty breathing with extreme exertion. C.D. does not know her blood pressure and average heart rate because she does not regularly keep track of these measurements. She experiences occasional edema in her feet and ankles as a result of sitting for long periods of time at work.

Gastrointestinal: The patient does not have any nausea, vomiting, diarrhea, or current constipation. She has a bowel movement approximately every other day.

Endocrine: C.D. does not appear to have any irregularities in menstrual flow, any level of thyroid dysfunction, nor adrenal dysfunction

Objective Data

T: 37.2 Celsius (oral), BP 140/82, P: 98, RR: 17, wt: 325 pounds, height: 5 feet

Generalized Appearance: C.D. appears to be healthy in spite of her obesity, well groomed, educated and articulate, nice smile and good teeth

Skin: No discolorations or abnormalities; mild acne on chin area, no rashes

Head: Atraumatic, normocephalic

Ears: No discharge was observed; tympanic membranes are gray and non-bulging; Eustachian tubes were closed; mild scarring, moderate amount of cerumen

Nose: Minimal nasal discharge, no odor; mucosa pink and moist; frontal sinus edema; sinus tenderness

Pharynx: Oral mucosa were moist and pink in color; no erythema, lesions, or exudate in the posterior osopharynx, uvula rose normally; gag reflex was normal

Neck: No masses, thyromegaly, or lymphadenopathy

Cardiac: No murmurs detected; heartbeat regular and rhythmic; S1, S2 were normal; S3 S4 had no murmurs; mild edema in the feet was observed but extremities were warm and perfused

Respiratory: Respirations appeared to be normal and no difficulty was observed; rales and diminished breath sounds were not observed

Abdominal: Abdomen soft, non-tender, non-distended; no masses, spleen size normal; bowel sounds positive

Neuro: Normal gait and mobility; full orientation to location and time

Labs: glucose 108, hemoglobin A1C 12.0, triglycerides 174; Results for STDs revealed; chlamydia +++++, trichomoniasis +++++, urinalysis bacteria +++++

Assessment

Primary diagnosis: Chlamydia and Trichomoniasis (although the woman has had only one sexual partner and infrequent use of condoms, it is likely that he has had multiple partners over the past few months)

Chlamydia is a very common sexually transmitted disease that is caused by Chlamydia trachomatis (CDC, 2014). This disease is characterized by an abnormal type of vaginal discharge and burning with urination, both of which the patient is experiencing (CDC, 2014). Trichomoniasis is caused by Trichomonas vaginalis and is characterized by symptoms such as itching in the vaginal area and an unusual type of vaginal discharge (CDC, 2014). Based on the symptoms that the patient presented with, my primary diagnosis is Chlamydia with a possible diagnosis of Trichomoniasis. I suspect that although the patient has only been with a single partner, he has been with one or more additional partners over the past few months which has contributed to this diagnosis. Positive test results indicate that the patient has both diseases, accompanied by a positive result for urinary tract infection.

Differential Diagnoses

Possible differential diagnoses for this patient include the following:

1. Pelvic inflammatory disease: this condition is characterized by vaginal discharge, pain during periods, spotting, fever, vomiting, pain during intercourse, and painful urination (Planned Parenthood, 2014). This disease, if left untreated, may lead to infertility, pain, and ectopic pregnancy on a long-term basis that could impact overall health and wellbeing (Planned Parenthood, 2014).
2. Vaginitis: this condition is characterized by abnormal discharge and subsequent odor, itching around the vaginal area, painful intercourse, and burning during urination (Cleveland Clinic, 2014). There are several different types of vaginitis, including viral, bacterial vaginosis, candida, and atrophic (Cleveland Clinic, 2014). Many of these conditions are treatable and also curable in patients (Cleveland Clinic, 2014).
3. Cervicitis: this condition is characterized by a change in vaginal discharge, painful intercourse, painful urination, and unusual vaginal bleeding (Mayo Clinic, 2014). Typically, this condition may coincide with one or more STDs that require treatment via antibiotics (Mayo Clinic, 2014). Therefore, avoiding sexual intercourse until the infection is cleared is highly recommended so that additional complications are not observed in the patient (Mayo Clinic, 2014).

Management Plan

Abdominal: it is recommended that the patient must receive drug therapy in antibiotic form to clear up the infection. Typically, metronidazole or tinidazole are used for Trichomoniasis, while amoxicillin, azithromycin (Zithromax), doxycycline (Doryx, Vibramycin), erythromycin (E-Base, Erythrocin), levoflaxin (Levaquin), and ofloxacin (Floxin) are used to treat chlamidia (WebMd, 2014). Each of these treatments may be recommended to treat patient infection. Fortunately, both conditions are treatable with antibiotics and may be cured without long-term complications or side effects. Therefore, the patient must commit to the treatment and finish her antibiotic regimens to achieve maximum effect that will have a positive impact on her overall health and wellbeing.

Sex education: it is important for this patient to confront her sexual partner and ask about his sexual history over the past few months. Based on her admittance of having only one partner and an infrequent use of condoms, it is clear that her partner had more than one sexual partner, if not multiple sexual partners, thereby contributing to her current diagnosis. Therefore, it is highly recommended that the patient is provided with counseling so that she is able to confront her partner regarding his behavior. In addition, she should not continue to have sexual intercourse with her current partner, at least until a discussion occurs regarding his behavior and his overall sexual history. These factors threaten the patient’s overall health and wellbeing for the foreseeable future if she continues to have sexual intercourse with her current partner, even with this diagnosis.

Reflection Notes

This assessment experience was based upon the framework provided through the SOAP protocol in order to determine the patient’s history, symptoms, diagnosis, and treatment regimen, as these factors contribute to an effective health plan for this patient moving forward. This information is particularly helpful in enabling the patient to be treated effectively and to have a greater understanding of her sexual behaviors and the partner(s) with whom she is participating in sexual intercourse. Based on the diagnosis and the possible reasons for both conditions, the patient soon realized that her partner had not been faithful to her and had spread both conditions to her. She was visibly upset by this revelation and appeared to understand that her behavior was also imperfect in that she did not use condoms during all sexual encounters. This placed her at greater risk and also demonstrated her level of trust in her sexual partner, which was not returned. This is an important revelation for the patient because it provides her with a reality check regarding her sexual behaviors and the partners whom she chooses to have sexual intercourse with in the future. If necessary, the patient should obtain psychological support and guidance in order to manage her response and any future discussions with her partner regarding his own sexual history and how it has impacted her health. This is a complex situation that should not be ignored by the patient, as her own health is at stake in this situation.

This assessment was a useful exercise because it provided a greater understanding of the key contributing factors to addressing a patient’s presentation, symptoms, diagnosis, and treatment. However, it also demonstrated the importance of new perspectives that could be effective in educating women regarding sexual behaviors and responsibility in this area, as these elements are critical to improving health and wellbeing over the long term. On the other hand, I feel as if this patient has a long way to go in order to preserve her health, as she possesses considerable challenges in her efforts to be successful in improving her health. Her weight is a primary concern and although it has not complicated the quality of her life significantly to date, this is likely to occur as she grows older and experiences other types of symptoms that may be directly attributed to her weight. Therefore, future assessments must focus more on her health with respect to weight and how she might be successful in improving her nutritional habits and in expanding her exercise regimen in order to achieve successful outcomes. These efforts are critical in achieving long-term success and in preserving her overall health.

References

Centers for Disease Control and Prevention (2014). Chlamydia – CDC fact sheet. Retrieved from http://www.cdc.gov/Std/chlamydia/STDFact-Chlamydia.htm

Centers for Disease Control and Prevention (2014). Trichomoniasis – CDC fact sheet. Retrieved from http://www.cdc.gov/StD/trichomonas/STDFact-Trichomoniasis.htm

Cleveland Clinic (2014). Vaginitis. Retrieved from http://my.clevelandclinic.org/disorders/vaginitis/hic_vaginitis.aspx

Mayo Clinic (2014). Cervicitis. Retrieved from http://www.mayoclinic.org/diseases-conditions/cervicitis/basics/definition/con-20026738

Planned Parenthood (2014). Pelvic Inflammatory Disease (PID). Retrieved from http://www.plannedparenthood.org/health-topics/stds-hiv-safer-sex/pelvic-inflammatory-disease-pid-4278.htm

WebMd (2014). Antibiotics for chlamydia. Retrieved from http://www.webmd.com/sexual-conditions/antibiotics-for-chlamydia