Week 5 APEA Predictor Assignment – Part 1

Week 5 APEA Predictor Assignment – Part 1

Week 5 APEA Predictor Assignment – Part 1

APEA predictor Assignment Part One

The condition discussed in this assignment can be considered under sexually transmitted infections or women’s health.

Week 5 APEA Predictor Assignment - Part 1

Subjective Information

Chief complaint: The patient was a 24-year-old black-American woman who presented with the chief complaint: “I have been having blood spotting after intercourse during the last four sessions of intercourse.”

History of present illness: The patient presents to the health care facility with complaints of bleeding after sexual intercourse. The bleeding was accompanied by pain in the pelvic region that the patient categorized to be a six out of 10 on the pain scale. The patient reported that she had no urine urgency changes. She reported having multiple sexual partners and uses no method of contraception because she trusts her partners.

Medical HX: The patient denied having any history of chronic diseases.

Medications The patient reported no current medications. However, she had taken acetaminophen to help with the pain.

Social HX: The patient lives alone in Washington D.C but travels around the country often. The patient reports no stressors in her life and has a good work-life balance. She has two sexual partners.

Drugs, smoking, or Alcohol HX: The patient reported that she does not use alcohol, cigarettes, cannabis, methamphetamines, and cocaine.

ROS

General: The patient appeared to be in no acute distress. She was well oriented in time, place, and person.

Head: She denies any form of lightheadedness, headaches, and head injuries.

Eyes, Ears, and Nose: She reported both eyes having a vision of 20/20 based on her last hospital visit. She denies ear pains or discharge. She also denies having any nose itching, rhinorrhea, and epistaxis.

Mouth/Throat:  The patient reported no changes in taste, no pain, no sore throat or gum issues.

Cardiovascular: She denied any history of claudication, palpitations, irregular heartbeats, and pain.

Respiratory: The patient reported nocturnal dyspnea, wheezing, or dyspnea on exertion.

Gastrointestinal: The patient reported the last normal bowel movement was the morning before coming to the hospital. She denied any bloating or diarrhea. However, she reported pain in the lower abdominal region that she graded as a 6 on a scale of one to ten.

Genitourinary: The patient did not report any changes in urine frequency or urgency. However, she reported having flank pain. She also reported having vaginal discharge that was greenish-yellow in color and very foul-smelling.

Musculoskeletal: The patient denied having a history of fatigue or body weakness.

Integumentary/breast: She did not report having any rashes, dimples, lesions, or pigmentation changes.

Neurologic: The patient denies any memory loss, gait changes, imbalance, or speech issues.

Endocrine: The patient reported having no heat intolerance, cold intolerance, polyuria, polydipsia, and polyphagia.

O – Objective

Vitals:

W: 153 lbs.

H: 5’6”

BMI: 24.7

O2 saturation: 99% in room air

HR: 84

RR: 17

BP 112/76

Temp: 98.2F

Pain: 6/10

HEENT: There was no tenting. The mucous membranes were observed to be moist and there was normal skin turgor.

Cardiovascular: S1 and S2 were patients but S3 and S4 being inaudible. The patient presented with no rubs, gallops, or murmurs. Furthermore, there was no lower extremity edema observed on both feet.

Respiratory: The respirations were quiet, unlabored, and normal with the breath sounds being clear on auscultation.

Abdominal: The abdomen of the patient was symmetrical. On auscultation, bowel sounds were audible in all four quadrants.

Musculoskeletal: There was no edema noted on the lower extremities bilaterally.

Integumentary: On examination, the skin was warm and dry. There was no tenting that was noted.

Neuro: The memory of the patient was found to be intact.

Hema: There was no bleeding or bruises noted on the patient’s skin.

Genitourinary: The patient presented with the presence of tenderness in the uterine region.

Week 5 APEA Predictor Assignment – Part 1 Assessment

Diagnostic testing:

  • Whiff test and vaginal Ph tests to determine the presence of Bacterial Vaginosis.
  • Sexually transmitted infection tests for trichomoniasis, gonorrhea, and chlamydia.
  • Pelvic exam

Differential Diagnosis:

  1. Pelvic Inflammatory Disease

Pelvic inflammatory disease can be described as an infection that affects one or more of the organs in the upper reproductive part including the fallopian tubes, uterus, and ovaries. The condition is mainly accompanied by mild to severe pain in the pelvic region and lower abdominal region (Curry, Williams & Penny, 2019). Other symptoms include pain after sexual intercourse, unpleasant abdominal discharge, and fever with chills. It may be caused by different factors but the main causative agents include gonorrhea, chlamydia, and trichomoniasis. The main risk factors include having multiple sex partners, being a young sexually-active woman, unprotected sex, and regular douching. The patient’s condition is most likely PID because she presents with several risk factors for the condition such as unprotected sex and having multiple partners. She also presents with unpleasant greenish-yellow discharge which may be indicative of the presence of trichomoniasis. Moreover, she also presents with two of the three cardinal features of PID which include cervical motion tenderness and tenderness in the uterine region.

  1. Endometriosis

Endometriosis is a condition in which tissue that resembles the innermost layer of the uterus grows on the outer layer of the uterus (Chapron et al., 2019, Week 5 APEA Predictor Assignment – Part 1 ). This condition usually presents with lower abdominal pain that may radiate to the back, rectum, or vagina. It also is accompanied by pain during sexual intercourse as well as spotting. However, the discharge produced in this condition is not greenish-yellow in color. The condition may be ruled out by the completion of a pelvic exam. The patient did not present with any pelvic abnormalities such as cysts in the examination process making this condition to be unlikely.

  1. Interstitial Cystitis

The condition is chronic and affects the bladder (Birder, 2019). It is usually accompanied by pelvic pain and sometimes spotting. However, this condition does not present with foul-smelling discharge as there is no infection in the bladder. Furthermore, it leads to changes in the frequency of urination making it the less likely condition be to affecting the patient.

Week 5 APEA Predictor Assignment – Part 1 References

Birder, L. A. (2019). Pathophysiology of interstitial cystitis. International Journal of Urology26, 12-15.

Chapron, C., Marcellin, L., Borghese, B., & Santulli, P. (2019). Rethinking mechanisms, diagnosis and management of endometriosis. Nature Reviews Endocrinology15(11), 666-682.

Curry, A., Williams, T., & Penny, M. L. (2019). Pelvic inflammatory disease: diagnosis, management, and prevention. American family physician100(6), 357-364.

The submissions for this assignment are posts in the assignment’s discussion. Below are the discussion posts for Elizabeth Polynice, or you can view the full discussion.

from Week 5: APEA Predictor – Part 2 Sample Client Work

Good evening Dr Wallace and Class

Treatment Plan for Pelvic Inflammatory Disease

Pelvic inflammatory disease can be described as an infection that affects the upper reproductive parts of females. This condition occurs as a complication of sexually transmitted infections mainly chlamydia, trichomoniasis, and gonorrhea (Reekie et al., 2018). However, it may occur as a result of other infections that are not necessarily transmitted sexually. There are no specific diagnostic tests for determining the presence of the condition. The diagnosis of this condition is dependent on a combination of physical examination, patient history, and other test results that help to determine the presence of an infection or rule out other conditions. The major symptoms associated with the condition include fever, lower abdominal pain, foul-smelling vaginal discharge, and pain during sexual intercourse among others. A treatment plan can be described as a detailed program that contains information about the disease of a patient, aims of treatment, available options for treatment, and expected duration of management.

Medications

The use of medications is crucial in the elimination of infections that may be causing pelvic inflammatory disease. It is important for this condition to be diagnosed and treated at an early age because the damage or scarring it causes in the uterus and fallopian tubes may be irreversible. The condition is mainly treated with a combination of antibiotics (Savaris et al., 2020). Initially, patients are treated with empiric therapy in suspected cases but with confirmatory lab results, the treatment regimen may be tailored to the specific causative organism. The current mainstay treatment is the use of two grams cefoxitin intramuscular injection accompanied with probenecid as a single dose. This regimen should also include 500 milligrams of metronidazole taken every 12 hours for two weeks and 100 milligrams of doxycycline taken once every twelve hours for two weeks. Alternatively, 250 milligrams of ceftriaxone may be administered in place of cefoxitin. Finally, the patient should be encouraged to bring all their sexual partners for treatment so as to avoid cases of re-infection.

Patient Education

Patient education can be described as the steps taken to influence the behavior of patients to produce changes in their attitudes, knowledge, and skills that are necessary for improving or maintaining health. A patient diagnosed with the pelvic inflammatory disease should be encouraged to abstain until all symptoms disappear. Patients with abstinence challenges can be encouraged to use protective barrier methods such as condoms. This is crucial to prevent the spread of the causative agents to other individuals. They should also be encouraged to bring their partners to health care facilities for screening, education, and treatment if they are found to be infected with the causative agents. Finally, the patient should be encouraged to take an HIV test and return to the facility in the event that the symptoms have not disappeared by the end of the treatment period.

References

Reekie, J., Donovan, B., Guy, R., Hocking, J. S., Kaldor, J. M., Mak, D. B., … & Chlamydia and Reproductive Health Outcome Investigators Liu B Preen D Hocking J Donovan B Roberts C Ward J Mak D Guy R Kaldor J Pearson S Stewart L Wand H Reekie J. (2018). Risk of pelvic inflammatory disease in relation to chlamydia and gonorrhea testing, repeat testing, and positivity: a population-based cohort study. Clinical Infectious Diseases66(3), 437-443.

Savaris, R. F., Fuhrich, D. G., Maissiat, J., Duarte, R. V., & Ross, J. (2020). Antibiotic therapy for pelvic inflammatory disease. Cochrane Database of Systematic Reviews, (8).