NR 602 Week 2 iHuman Case 2 - Nancy Campbell

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Institution	NR 602 Primary Care of the Childbearing and Childrearing Family
Contributor	Racheal Ofori

Description

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Problem statement sample: NM is an 18 year old college student with history of childhood asthma who presents with acute onset of low-grade fever, fatigue, myalgia, right ear pain and headache. Physical exam reveals an erythematous pharynx and right tympanic membrane, anterior cervical adenopathy, and scattered bilateral crackles. Risk factor include lack of an annual flu vaccine.

• 10 more in Associated Symptoms

• 1 more in SH

•

My problem statement:

NC is a 25-year-old woman with a 3-day history of dysuria, increased urinary frequency and yellow, creamy, and mucous-like discharge. Denies fever, chills, myalgia etc. Physical exam reveals mucopurulent discharge from cervical os, cervix appears friable with a vaginal pH of 4.0. Risk factor includes multiple sexual partners, not using any protection against STIs and on birth control.

Mother: diabetes mellitus Father: HTN, CAD, hyperlipidemia Older sister: Alive and well

Works as a consultant; travels frequently

Alcohol: 1 to 2 times per week; 4 to 5 drinks per occasion No other substance use

Previous-smoker status: approximate 2 pack-year hx

Patient Information: Nancy Cambell Name and Age: 25 years old Height and Weight: 135 lbs

Vital Signs: #/# BP, # HR, # RR, # O2%, # Temp. 98.7, 78, 110/72, rr 14, 94ra

CC: 25 yo with pain with urination HPI:

Problem Statement: Short summary of patents presentation. Should contain:

1: Demographic description

2: Chief complain 3: Hx and PE key 4: Risk factors

Key Findings (# Key Findings):

Good Questions:

(Interviewing Question) How can I help you today? “Patient’s complaint” I have burning when I pee. I was worried that I had another bladder infection but these symptoms are a little different then the symptoms I had with my last UTI.
(Interviewing Question) Do you have any other symptoms we should discuss? Vaginal discharge
Has there been a change in your urinary frequency? Well, yeah. Seems like I feel I have to go every 10 to 15 or 20 minutes but I resist due to the pain.
When did pain with urination start? About 3 days ago
Is the pain better or worse at the start of urination? Worse when starting but it doesn’t really let up.
What is the appearance, smell, texture and quantity of the vaginal discharge? Yellow, king of mucousy, kind of creamy, not really too smelly.
Do you have vaginal discomfort or itching? No
How severe is your pain/discomfort with urination? Makes me not want to go even though I have to! ................... Continue