i have vaginal itching and burning, earache, and sore throat

Name:  W.F.	Date: 6/12/17	Time: 1430
	Age: 58	Sex: F
SUBJECTIVE
CC: “I have vaginal itching and burning, earache, and sore throat”
HPI: W.F. is a 58 y/o white female with a history of vaginal itching and burning.  She was treated in October 2014 with Acyclovir for r/o genital herpes.  She was instructed to follow-up with primary physician but she did not due to “not being able to afford it”.  She states the vaginal irritation did not completely alleviate but was getting better for a while.  Patient states pain got better but now has been experiencing increased itching for the last four days.  States she has been using Aveeno lotion to soothe the itching and burning but it is no longer working.  Denies internal vaginal itching and irritation.  Also denies any associated symptoms.  Patient report ear pain x 2 weeks with notice of sore throat off and on since last night.  Describes throat as scratchy without cough.  She denies any use of OTC medication to treat sore throat or ear pain.
Medications: Ibuprofen 1-2 tabs prn for minor aches
PMHAllergies:  NoneMedication Intolerances: NoneChronic Illnesses/Major traumas: History of cocaine drug use.Hospitalizations/Surgeries: Denies any hospitalizations outside of vaginal birth 31 years ago. Tonsillectomy as a child
Family HistoryW.F.’s parents are deceased. Her mother died in 2006 from heart disease and she is unsure of the reason for father’s death in 2010.  Maternal grandmother is deceased from massive heart attack and unsure of maternal grandfather and paternal grandparents cause of death.   She has one living brother in Alabama that may have diabetes.  W.F. has one daughter that lives three hours away with no health problems.
Social HistoryPatient is single and never was in a relationship with the father of her child.  She is not in a relationship at this time.  She is a GED graduate that now works as a housekeeper in environmental services.  Patient admits to cocaine drug use but has been clean through self-detox for the last 15 years.  She admits to pack/day cigarette smoking and admits to social alcohol drinking less than three times per month.  Attends church on occasions.  States she gets along well with co-workers but is mainly friends with two of her neighbors.  No immediate family in the area.  She participates in employer health plan.
ROS
GeneralDenies weight change.  “I work 24-30 hours per week, I am always tired”.  Denies fever or chills	CardiovascularDenies chest pain, palpitations, or edema
Hair, Skin, and NailsVaginal rash, none on other body parts	RespiratoryDenies cough, wheezing, SOB
EyesDenies visual changes; wears glasses. Dark circles under eyes from vaginal itching awakening	GastrointestinalDenies abdominal pain, n/v/d, or bowel changes. Denies black stools
EarsDenies hearing loss or tinnitus; outer ear pain x 2 weeks; denies trauma but sore on left ear	Genitourinary/GynecologicalDenies dysuria, hematuria, urgency or frequency. Admits to vaginal itching and burning x 4 days. Denies sexual activity. Denies vaginal odor or excessive discharge
Nose/Mouth/ThroatNo Sinus problems, nose bleeds or discharge. Scratchy throat. Denies dysphagia or hoarseness	NeurologicalSyncope, seizures, transient paralysis, weakness, paresthesias, black out spells
LymphaticsSmall knot behind ear	PsychiatricNo diagnosis.  Some depression at times. No suicidal ideations. Difficulty sleeping when experiencing vaginal irritation.
OBJECTIVE
Weight: 211       BMI 38.6	Temp 98.6	BP138/88
Height 62”	Pulse 66	Resp18
General AppearanceHealthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
SkinSkin is warm and dry, clean and intact. No rashes or lesions noted. Age appropriate wrinkles noted.
HEENTHead is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. Sclera and conjunctiva clear.  Small amount of edema to lower eyelids with dark circles. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Three healing scars/sores less than 0.5cm in diameter noted to left external ear and helix. Denies painful palpation of helix, auricle, or pinna. Nose: Nasal mucosa pink; normal turbinates. No septal deviation or discharge. Neck: Supple. Post auricular lymph node, non-tender, less than 0.2cm. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth decay noted
CardiovascularS1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
RespiratorySymmetric chest wall. Respirations regular and non-labored; lungs clear to auscultation bilaterally.
GastrointestinalAbdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
GenitourinaryBladder is non-distended; no CVA tenderness. External genitalia reveals no pubic hair from grooming; no lesions noted but external brownish rash to labial minor and major. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink. Scant clear to white discharge noted.
MusculoskeletalFull ROM seen in all 4 extremities as patient moved about the exam room.
NeurologicalSpeech clear. Good tone. Posture erect. Balance stable; gait normal.
PsychiatricAlert and oriented. Dressed in work uniform. Maintains eye contact. Speech is clear and normal rate. Answers questions appropriately.
Lab TestsUrinalysis – No ketone, nitrites, or WBCs
Special Tests: none
Diagnosis
Differential Diagnoses· 1-Vaginitis- usually involves inflammation. It can result in discharge, itching, and pain (Mayo Clinic, 2015).· 2-Hypersensitivity- allergy or contact dermatitis is a possible cause of vaginitis symptoms.  Feminine hygiene products, soaps, clothing detergents, bubble bath are some offending agents (Buttaro, Trybulski, Bailey, & Sandberg, 2015; Cash & Glass, 2014).· 3- Trichomonas- the presenting complaints are discharge and itching. It can be differentiated from yeast the discharge, which is usually thin and frothy rather than thick discharge of yeast (Goolsby & Grubbs, 2015)Diagnosis: 112.1 Candidias- Goolsby & Grubbs, 2015 suggest that intense vulvar itching can accompany a discharge. Inflammation can cause dyspareunia and burning of the labia
Plan/Therapeutics
· Plan: · Further testing– if symptoms are not relieved within 1 to 2 weeks then the patient instructed to follow-up for possible GYN referral (Buttaro et al., 2013)· Medication-Nystatin cream to external vagina BID X 7 days (Cash & Glass, 2014)·  Bactrim DS BID 7 days PO·   Diflucan 150mg PO after antibiotic completion (Buttaro et al., 2013)· Education: Patient educated to not use douches and stringent detergents. Do not use any lotions or soaps to vaginal areas, no tight clothing, and wear cotton underwear (Buttaro et al., 2013).  Do not scratch and keep nails short.  Patient also needs to complete all antibiotics.
Evaluation of patient encounter:  I felt comfortable addressing this patient complaint.  However, I was able to assess the patient and she felt like the education was going to be beneficial.  This patient was shaving every other day. So being aware of some of the non-pharmacological interventions was helpful.

References

Buttaro, T., Trybulski, J., Bailey, P., & Sandberg, J. (2013). Primary care: A collaborative practice. St. Louis, MO: Elsevier Mosby

Cash, J. & Glass, C. (2014). Family practice guidelines: 3rd edition. New York, NY: Springer Publishing Company, LLC

Goolsby, M. & Grubbs, L. (2015). Advanced assessment: Interpreting findings and formulating  differential diagnoses, 3rd edition. Philadelphia, PA: F.A.       Davis Company

Mayo Clinic (2015).  Vaginitis. Retrieved from www.mayoclinic.org

 

"Looking for a Similar Assignment? Get Expert Help at an Amazing Discount!"