Best Practice & Research Clinical Obstetrics Assignment

Patient Information:

Initials: H. R.               Age: 18yo                Sex: F

S.

CC (chief complaint): “Lower abdominal pain.”

HPI: The client, H. R., is an 18yo female. She presented to the office a chief complaint of lower abdominal pain. The client reports a burning sensation while urinating, increased urination urgency and frequency, and cloudy urine for the last three days. Denies using over-the-counter treatment to manage the abdominal pain.

Current Medications: Denies current medication therapy Best Practice & Research Clinical Obstetrics Assignment

Allergies: H. R. denies known allergies

PMHx: She denies past medical conditions.

Soc Hx: H. R. is a college student. She denies having a partner. She is the firstborn in a family of three. She lives in the city with her mother and her younger. She denies using illegal substances, alcohol, or tobacco. She is a strong Christian and committed to church activities.

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Fam Hx: The client’s paternal grandparents died during an earthquake occurrence. Her maternal grandmother and grandfather are alive at 83 and 89 years, respectively. Her mother is happening at 50 years old with asthma. Her father died in a car accident two years ago. Her younger sisters, aged 14 and 9 are alive and healthy. Best Practice & Research Clinical Obstetrics Assignment

ROS:

GENERAL: H. R. reports a fever.

HEENT: H.R. denies head scar. Denies eye injuries. Denies ear infection. Denies sneezing. Denies oral thrush.

SKIN: Denies cracked or rough skin

CARDIOVASCULAR: The client denies edema.

RESPIRATORY: H. R. denies dry cough

GASTROINTESTINAL: Reports lower abdominal pain

GENITOURINARY: The client reports a burning feeling while urinating. Reports cloudy urine. Reports increased urination urgency and frequency.

NEUROLOGICAL: The client denies ataxia

MUSCULOSKELETAL: T. R denies back pain

HEMATOLOGIC: She denies abnormal bleeding

LYMPHATICS: The client denies swollen lymph nodes.

PSYCHIATRIC: She denies depressed mood.

ENDOCRINOLOGIC: She denies increased sweating

ALLERGIES: H. R. denies a history of hives Best Practice & Research Clinical Obstetrics Assignment

O.

Physical exam:

Vitals: BP 138/86; RR 19, Pulse 98, Weight 57 kgs, T 39°C, and Height 5 “3”.

General: The client is presentable and well-groomed. She appears healthy and appropriate for her age. Remains attentive during the clinical interview.

HEENT: No scars seen on her head. No tears in her eyes. Her tympanic membranes are well-developed. No fluid was seen on her nostrils. No lesions in her mouth on examination.

Abdomen: The suprapubic region is tender on exertion

Pelvic region: Pain was detected on her right lower quadrant on examination

Diagnostic results:

Urine dipstick: Positive for nitrates and leukocytes Best Practice & Research Clinical Obstetrics Assignment

A.

Differential Diagnoses

Urinary tract infection (UTI): UTI is a common diagnosis in female teenagers. Teenagers with UTI experience a burning sensation with urination. Others report lower abdominal pain, frequent urination, cloudy or pink urine, and increased urination urgency (Srivastava, 2018). The client’s chief complaint is lower abdominal pain. Other pertinent positives include a burning sensation when urinating, cloudy urine, increased urination urgency, and frequent urinating frequently. During a pelvic exam, the client’s suprapubic region was tender on exertion, and pain was detected in her right lower quadrant. Lastly, her urine dipstick was positive for nitrates and leukocytes, making UTI the most appropriate primary diagnosis.

 Bacteria Vaginitis: The client reports urination, a pertinent symptom of bacteria Vaginitis. However, bacterial vaginitis is disqualified due to the absence of the most pertinent symptoms, including excess vaginal discharge, inflammation or soreness around the genitals, and vaginal irritation or itching (Paladine & Desai, 2018). Best Practice & Research Clinical Obstetrics Assignment

Trichomonas vaginalis: The most common symptoms are itching, burning, pain while urinating, redness around the vagina, and excess and colored vaginal discharge (Wynn et al., 2018). The pertinent positive is a burning sensation while urinating. Nonetheless, Trichomonas vaginalis is disqualified due to absence of some pertinent symptoms, including abnormal vaginal discharge.

Candida albicans: In teenagers, Candida albicans is manifested through soreness in genital parts. Additionally, individuals with this condition experience burning sensation with urination and increased vaginal discharge (Loveless & Myint, 2018). H. R. reports a burning feeling with urination. Nonetheless, Candida albicans is disqualified due to absence of pertinent symptoms, such as excessive vaginal discharge. Best Practice & Research Clinical Obstetrics Assignment

References

Loveless, M., & Myint, O. (2018). Vulvovaginitis-presentation of more common problems in pediatric and adolescent gynecology. Best Practice & Research Clinical Obstetrics & Gynaecology, pp. 48, 14–27.

Paladine, H. L., & Desai, U. A. (2018). Vaginitis: diagnosis and treatment. American Family Physician, 97(5), 321-329.

Srivastava, S. (2018). Analytical study of urinary tract infection in adolescent girls. International Journal of Reproduction, Contraception, Obstetrics, and Gynecology, 7(4), 1385-1389.

Wynn, A., Ramogola-Masire, D., Gaolebale, P., Moshashane, N., Sickboy, O., Duque, S., … & Morroni, C. (2018). Prevalence and treatment outcomes of routine Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis testing during antenatal care, Gaborone, Botswana. Sexually Transmitted Infections, 94(3), 230–235. Best Practice & Research Clinical Obstetrics Assignment