FULL CLASS:
NURS 6512 – Advanced Health Assessment and Diagnostic
Patients are frequently uncomfortable discussing with healthcare professionals issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies can help prepare advanced practice nurses to accurately assess patients with problems in these areas.
For this i-Human Patients Case Study Assignment, you will examine and work with a patient with a condition of the genitourinary and/or reproductive system.
To prepare:
- By Day 1 of this week, your Instructor will assign an i-Human Patients case for this Assignment. Note: Please see the Course Announcements section of the classroom for your i-Human Patients Assignment.
- Review this week’s Learning Resources on the genitourinary and reproductive systems.
- Access and review this week’s i-Human Patients case study. Based on the provided patient information, think about the health history you would need to collect from the patient.
- Consider what physical exams and diagnostic tests would be most appropriate to gather more information about the patient’s condition.
- Reflect on how the results would be used to make a diagnosis.
- Identify three to five (3–5)possible conditions that may be considered in a differential diagnosis for the patient.
- Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
- Develop a treatment plan for the patient that includes health promotion and patient education strategies.
Assignment
As you interact with this week’s i-Human Patients patient, complete the assigned case study. For guidance on using i-Human Patients, refer to the i-Human Graduate Programs Help link within the i-Human Patients platform.
Solution
Problem Statement by Student’s Name on case Juliana Mirabelles
Patient J.M is a 25-year-old female who presents with complaints of burning sensation during urination. This problem started 3 days ago. Other symptoms include urinary urgency and…
Management Plan by Student’s Name on case Juliana Mirabelles
Diagnostic tests:
Urine culture: no bacterial growth
Neisseria gonorrhea PCR: +ve
Neisseria gonorrhea culture: +ve
Chlamydia trachomatis culture: No chlamydia
Saline wet amount: leukocytes present
Urinalysis (UA): +ve for leukocytes, elevated WBC
HIV 1 and/or 2 antibody, blood: -ve
Potassium hydroxide (KOH) preparation test: -ve for candida
Medications: Ceftriaxone 500mg IM
Referrals: No referrals at the moment
Client Education: Patient need to be educated about gonorrhea and other STDs. One of the best ways to prevent STDs is to abstain from any sexual activity; however, given that the patient is sexually active, she need to
Electronic Health Record by Student’s Name on case Juliana Mirabelles
History of Present Illness
Category Data entered by Student’s Name
Reason for Encounter “I have been burning when I pee. I was worried I had another bladder infection, but these symptoms are a little different than the symptoms I had with my last UTI”
History of present illness The patient is a 25-year-old heterosexual female. She presents to the office with c/o dysuria, burning during urination, and vaginal discharge. Her symptoms began three days ago. She is unsure of the events surrounding the start of these issues. Her vaginal discharge can be characterized as yellow, kind of mucousy, kind of creamy, not too smelly…………………..$10