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Lara, Ivet

Dec 3, 2020 at 19:51

Module 7- Case Study #2

In the diagnosis and treatment process of the patient, as a clinician one relied upon the subjective and objective data collected from the patient. According to the case of a 19-year old female who has been experiencing pain during urination and when having intercourse, the physical exam will be relied upon. My physical assessment will help in finding if the patient is showing vital signs like tachypnea, fever, and tachycardia (Nambiar et al., 2018). Besides, there will be a need of assessing the CVA tenderness, percussion, or palpation. Other health aspects that will be assessed on the female patient is urine abnormalities like the presence of blood, foul odor, sediment, cloudiness, etc. The hydration status of the patient will also be assessed like urine output, fluid intake, and skin turgor (Nambiar et al., 2018). Consequently, there is a need of finding the possibility of pregnancy and medical history linked with reproductive problems. Lastly, there is a need of assessing whether a patient is experiencing nausea, vomiting, tenderness, and pain in the upper back.

For an in-depth assessment of the health conditions of a patient, objective data will be relied upon. There will be a need of examining the presence of bacteria and white blood cells in the urine (Nambiar et al., 2018). Thus, a count of white and red blood cells will be conducted. Measuring the level of fever will also be relied upon to determine the severity of her conditions. The conditions of the bladder will also be assessed to cross-check if there are abnormal conditions. Additionally, to diagnose her health conditions, some possible diagnostic tests or exams will be put into consideration such as urine culture, urinalysis, CT scan, ultrasound, and cystoscopy. Ultrasound will help get an image concerning the internal organs by examining the sound waves. The cystoscopy will be relied upon to check the condition of the bladder for further assessment. Urinalysis is a diagnostic exam that will help in examining the bacteria, white blood cells, and red blood cells (Nambiar et al., 2018). The last possible diagnostic exam is the urine culture. This will help in assessing the kind of bacteria present in urine.

As per the signs and symptoms of the patient, the possible differential diagnoses are vaginitis, infected skene gland cyst, and pathogenesis. Pathogenesis is a kind of acute infection inflammatory condition that typically travels from an upper genital tract via the vagina. Additionally, vaginitis is another possible health condition since it is linked with vaginal discharge and vaginal irritation. Lastly, an infected skene gland cyst may also be a health problem of a patient since it is linked with signs and symptoms like urethral pain, the urgency of urinating, and the high-frequency rate of urinating (Mota, 2017). The chosen differential diagnosis is because the signs and symptoms are closely linked to the ones shown in a 19-year old female patient. Additionally, in conducting diagnosis the three health conditions also rely on almost the same diagnostic exams or tests.

Health education is crucial for treatment and prevention purposes. For instance, to prevent these conditions from re-occurrence, a patient will be required to empty the bladder empty once a patient develops an urge, wiping from front to back, get rid of using feminine deodorants, urinate after sex, engage in pelvic muscles exercises, and change sanitary pads often (Mota, 2017).

References

Mota, R. L. (2017). Female urinary incontinence and sexuality. International braz j urol, 43(1), 20-28.

Nambiar, A. K., Bosch, R., Cruz, F., Lemack, G. E., Thiruchelvam, N., Tubaro, A., & Schneider, M. P. (2018). EAU guidelines on assessment and nonsurgical management of urinary incontinence. European urology, 73(4), 596-609.