Question

Chief Complaint: “I’m having a lot of vaginal discharge and it really itches”.

Teresa Nguyen, a 28 yo Vietnamese American woman, is being seen in the clinic for the first time with heavy vaginal secretions and pelvic Pain. She takes no medication.

Vitals: T 37C, P 82, R16, BP 102/66

1. What other subjective information should the nurse gather about Ms. Nguyen’s situation for the History of the Present Illness?

1. For the past Medical History?
2. For the Family History?
3. For the Psychosocial History?
4. For the Review of Systems?

2. What objective assessments should the nurse preform for Ms. Nguyen?

1. Based on the information given, how would the objective data be written up? (see book for examples)
2. Based on her subjective complaints, how would you need to conduct the physical assessment?

3. What is the appropriate intervention for Ms.Nguyen ?

Answer 1

She should gather information like :

when did the bleeding start?

what is the quantity in terms of wetting pads? ( blood-soaked )

From where does the pain radiate?

When did itching start?

Is there any trauma?

a. For the past medical history following can be asked

• Do you notice a strong vaginal odor?
• any multiple sexual partners
• Do you use any scented soap?
• Do you douche or use the feminine spray?

The patient should be asked to list any major medical illness that she had in the past.

b. It includes the illness experienced by family members like cancer, HIV, DM, etc. This helps to diagnose the condition easily.

c.The socio history of the patient includes her marital or relationship status and occupation.

d.Review of systems.

1. Abdomino-pelvic.
   1. Gynecologic.
      1. Abnormalities of uterine bleeding. The gynecologic review of systems for the premenopausal woman includes an assessment of abnormalities of intermenstrual interval and menstrual flow.
      2. Pelvic pain. Pelvic pain should be characterized as cyclic or noncyclic.
      3. Symptoms of uterine prolapse.
      4. Vaginal dryness. Dryness or decreased lubrication may be noted when estrogen levels are low postpartum or at the time of menopause
      5. Vulvar pruritus or burning. The patient should be asked about symptoms of vulvar pruritus and burning, which may be symptoms of vulvo-vaginitis.
   2. Urinary symptoms.
   3. Symptoms of urinary tract infection include dysuria, urinary frequency, urinary urgency, and hematuria.
   4. Symptoms of urolithiasis include flank pain and hematuria.
   5. Gastrointestinal symptoms. Patients should be asked about symptoms of nausea, vomiting, constipation, diarrhea, blood with the stools, pain with defecation.
   6. Breast. Patients should be asked about the presence of breast masses, discharge, pain, and a prior history of breast biopsy.

a.Fron the above finding patient discharge is like cottage cheese-like, fish like odor and the intensity of the patient pain on pain scale is 4/10 as by patient observation .

b. For this Pelvic examination should be conducted where the doctor uses the instrument called a speculum to look inside the area for any inflammation or abnormal discharge.

Some time nurse or doctor may collect a sample of the cervical discharge to confirm what type of infection is it.

The infection can be caused by various microorganisms so, the treatment depends upon the type of infection caused.

The most important step is maintaining hygiene.

The cervix are inspected for lesions.The examiner assesses any vaginal discharge that is present for normalcy in appearance, color, consistency, and odor.