Syphilis Patient Soap, Essay Example

Subjective

Chief Compliant

The patient entered the emergency room with a wet cough and a high fever of 105. The patient had several complaints but the primary compliant was the cough. Secondary complaints: vaginal pain, pain all over body, headaches, and eyes were red and yellow. It was challenging to determine which symptoms were accurate. The patient was not forthcoming with answers such as indicating she did not smoke, drink, or take drugs. However, previous records indicate the patient is a heavy chain smoker, alcoholic, and drug addict.

History of Patient: 17 year female patient arrive at the emergency room complaining of coughing and rashes from head to toe. The patient’s rash involved primarily around the vaginal area including skin, face sores, and palms. The rash was not very painful nor pruritic and had changed minimally since its onset 2 months earlier. The review of systems at the intake was high fever 105, sore throat, vaginal pain, dry cough, and sinus congestion. Her past medical history included previous diagnosis of syphilis at age 15. The patient was a nonsmoker, nondrinker, and reportedly had been sexually active over the past year. She had a history of pain killers and methamphetamine abuse. She quit one 1 year ago. She also had allergies to ciprofloxacin, Bactrim, and amoxicillin.

Medications

Doxycycline hyclate oral 50 mg once a day

Minocycline oral 50 mg once a day

Penicillin G benzathine 20 mg once a day

Doxycycline calcium oral  4 mg once a day

Erythrocin Stearate oral  8mg once a day

Allergies: Drug allergies is sulfur or food allergies mushrooms. Patient has allergies to ants and freshly cut grass during the summer

Past Medical History: heavy smoker, Jaundice, Cancer of throat

Past Surgical History: Past surgery throat cancer

Personal/Social History: The patient smoked three pack of cigarettes per day for 7 years. Still currently smoking. Drinks alcohol on occasion. Denies any drug use. States he does not exercise regularly and is not on any special diet, but is trying to start a diet and exercise program.

Immunizations: Up to date

Family History: His mother and father both have heart disease that runs in the family lines. They both had heart attacks at the ages of 38 and 35. She has no other siblings or children.

Review of Systems:

General: patient is extremely obese, has fever, body pain, fatigue, or nose excessive sneezing.

Skin: patients has rashes, no mumps, and dryness of skin.

Eyes: Blurred vision, patient has vertigo. No eye docket pain. Has nose is leaking liquid yellow substance

Ears: The patient has hearing loss in left ear from previous accident as a child. No other recent hearing loss. No eardrum problems no ear pressure

Nose: Patient has seasonal allergy brought on by freshly the cut grass. The inside of nose has lesions and raw inner walls. Patient has no nasal congestion.

Throat: Patient has sore and raw throat. Patient is very hoarse barely able to make a sound. The gums are bleeding but no dry mouth. No problems swallowing.

Neck: is Supple without any other indication of swelling or discomfort.

Respiratory: Patient has constant cough and wheezing

Cardiovascular: The patient heart beats moving very fast, no events with chest pain. Patient has a family history of diabetes. The patient is Type II and her readings from the pharmacy is always too high. Patient indicates mother owns friend chicken stand, she has a plate of friend chicken every day.

Gastrointestinal: She has no constipation or stomach issues no nausea or vomiting.

Endocrine: Patient has history of DM type 2 however, have problems with taking medication because of throat problems.

Objective Data:

Temp 104, Blood Pressure 151/125, Pulse: 94, wt: 350

Patient appearance is hunched and the extremely overweight. Patient BMI is 43.7

Skin: Patient has skin rashes but no lumps or nodules.

Head: Atraumatic  the therapies and devices no tissue damage unlikely. Head is normal in condition without any abnormalities. Patient is Normocephalic

Ears: Ear membranes are normal with no bulging. No wax buildup. No drainage noted.

Nose: Nose is moderate and clear. No mucus and clear nasal paths. No discharges.

Pharynx: No lesions Uvula is normal , patient swallow test normal and patient is not hoarse.

Neck: Neck is supple, no other issues, masses, or protrusions.

Cardiac: The patient has no murmurs and the heart rhythm is regular.

GU: Not Done

Neuro: Normal gait but will a limp. Patient not oriented

Labs: hemoglobin normal

Assessment:

Diagnosis: Syphilis

1. Syphilis: This condition occurs when the patient has sexual contact with someone who was infected. The RPR test and a Serologic test which confirmed that the patient has a severe case of syphilis. This is the primary diagnosis. More common in females. The primary reason for the diagnosis because it is a classic description and symptoms of the syphilis disease. The patients in China has the same rate of high causes of syphilis with females that are dying (Yang al et. (2011).
2. Gonorrhea-The symptoms resemble gonorrhea tested urine for bacteria which came back negative. The gonorrhea tests were screened for infections. Infection was found in urine.
3. Chlamydia- These symptoms were lower abdominal pain, vaginal discharge and painful urination which is consistent with Chlamydia however, prevailing ongoing symptoms that were much more prevalent were severe joint pain, non-itchy red spots, swollen lymph nodes, and ulcers which confirmed syphilis. Chlamydia was r/o dx.

Plan:

The primary plan for the patient is to run a set of diagnostics make sure other organs are healthy. In addition, requesting a throat and chest radiology test. In addition, for the syphilis will order blood test to find out what other diseases that may be aggravating the illness. The study in China indicated there is an epidemic of syphilis amount young people that needs to address with more research (Liu, Wang, Gue, Dong & Shan (2012).

A full variety of tests will be completed concerning the detection of syphilis and spinal fluid exams and an echocardiograms. The patient will be treated with antibiotics instead of other allergic medicines. The patient is addicted along with penicillin for the treatment of the advance stages or syphilis. According to CDC, Penicillin is the treatment of choice for treating syphilis. According to the Centers for Disease Control and Prevention (CDC) recommends any patient with syphilis should be treated with penicillin and a test for allergy of the skin testing. (Centers for Disease Control and Prevention (2013), as cited in Medcape, 2013). The patient should follow up with primary physician and pain management. The drug abuse counselor needs a referral to regulate the patient taking penicillin.

Assessment

The patient was work-up with a series of blood work revealed the patient has an elevated anemic hemoglobin’s level and increased levels of blood hematocrit levels. The patient was having problems with her body not creating enough white blood cells in the spinal cord. This was getting slowed down when passing through the lymph nodes. A blood test concentrated on the antibodies which had a large amount of these antibodies that indicate that she has a severe case of syphilis virus. The syphilis disease is an infectious disease that is transmitted from contact from another individual sexually that transfer this disease into the patients’ blood system (Tampa, Sarbu, Benea & Georgescu, 2014). The  patients spinal fluid indicate a very bloody area with an increase glucose levels, elevated levels of protein and above level of normal for red blood cell count, and elevated white blood cells.. A skin punch biopsy showed skin issues with positive inflamed reactions. A detailed report of the syphilis disease confirmed the presence of HIV. The correct treatment for this disease would be injections of penicillin to fight off any infections that may cause the patient’s death. The mortality rate for syphilis for women are on the rise so there is concern for this patient. According to jones indicated that the medical community needs to address the number of female patient’s deaths from syphilis (Gomez, Kamb, Newman, Boutet & Hawkes, 2013, pg.225.)

Reflection notes

I would have ordered out all the previous physicians’ medical records to determine the true answers to the patients past medical history and mental state. The patient was unreliable and the skin lesions are unremarkable but cannot r/o some other serious conditions that may be present.

References

Gomez, G. B., Kamb, M. L., Newman, L. M., Mark, J., Broutet, N., & Hawkes, S. J. (2013).

Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis. Bulletin of the World Health Organization, 91(3), 217-226. doi:10.2471/BLT.12.107623

Liu, J., Huang, Y., Wang, J., Guo, N., Li, J., Dong, X., & … Shan, H. (2012). The increasing prevalence of serologic markers for syphilis among Chinese blood donors in 2008 through 2010 during a syphilis epidemic. Transfusion, 52(8), 1741-1749. doi:10.1111/j.1537-2995.2011.03527.x

Tampa, M. M., Sarbu, I. I., Matei, C. C., Benea, V. V., & Georgescu, S. R. (2014). Brief History of Syphilis. Journal of Medicine & Life, 7(1), 4-10.

Yang, L., Tucker, J. D., Wang, C., Shen, S., Chen, X., Yang, B., & Peeling, R. (2011). Syphilis test availability and uptake at medical facilities in southern China. Bulletin of the World Health Organization, 89(11), 798-805. doi:10.2471/BLT.11.089813