L.R. is a 28-year-old female patient who was evaluated at the clinic because she presented thin and white vaginal discharged which was increased after sexual intercourse.
The vaginal discharge has a pH of 5.2, positive KOH test and clue cells (more than 40% of epithelial cells) on microscopic examination.
Questions to answer:
List your Primary diagnosis with ICD 10 number.
Discuss three differential diagnoses for AUB with ICD 10 numbers for each.
Discuss patient education.
Develop the management plan (pharmacological and nonpharmacological).
An effective health assessment incorporates not only physiological parameters; please suggest other parameters that should be considered and included on health assessments to reach maximal health potential on individuals.
Name the different family developmental stages and give examples of each one.
Describe family structure and function and the relationship with health care.
Sample Answer
L.R.'s symptoms and lab results point to a primary diagnosis of Bacterial Vaginosis (BV). The ICD-10 code for Bacterial Vaginosis is N76.0.
Differential Diagnoses for AUB
The prompt mentions "AUB" (Abnormal Uterine Bleeding), but the patient's symptoms are related to vaginal discharge, not bleeding. Assuming the patient had presented with AUB, three possible differential diagnoses are:
Uterine fibroids (Leiomyoma of uterus) (ICD-10: D25.9): These are noncancerous growths of the uterus that can cause heavy or prolonged menstrual bleeding, known as menorrhagia.
Endometrial polyps (ICD-10: N84.0): These are overgrowths of the lining of the uterus (endometrium) and can cause irregular bleeding between periods or heavy bleeding during menstruation.
Anovulatory uterine bleeding (ICD-10: N93.9): This type of bleeding occurs when a woman does not ovulate, leading to an imbalance of hormones that can cause irregular, heavy, or prolonged bleeding.
Patient Education
L.R. should be educated on the nature of Bacterial Vaginosis and how to prevent recurrence. This includes:
Understanding the condition: Explain that BV is a common imbalance of the normal vaginal flora, not a sexually transmitted infection (STI), though sexual activity can disrupt the balance.
Treatment Adherence: Emphasize the importance of completing the full course of prescribed medication, even if symptoms improve, to ensure the infection is fully resolved.
Hygiene Practices: Advise against douching, as it can disrupt the natural pH of the vagina and increase the risk of BV. Suggest using mild, non-irritating soaps for external cleaning and to avoid scented feminine products.
Lifestyle Factors: Discuss the potential link between new or multiple sexual partners and BV, and suggest a consistent partner may reduce recurrence.
Management Plan
Pharmacological
Metronidazole: Prescribe oral metronidazole (500 mg twice daily for 7 days) or metronidazole vaginal gel (one applicator full nightly for 5 days).
Clindamycin: An alternative is clindamycin cream (one applicator full nightly for 7 days) or oral clindamycin (300 mg twice daily for 7 days).
Nonpharmacological
Probiotics: Recommend oral or vaginal probiotics containing Lactobacillus species to help restore the normal vaginal flora.
Lifestyle modifications: Advise L.R. to avoid douching and tight-fitting clothing, which can trap moisture and heat. She should also be advised to use cotton underwear.
Other Health Assessment Parameters
To reach maximal health potential, a comprehensive health assessment should go beyond physiological parameters to include:
Social Determinants of Health: Factors like socioeconomic status, education level, access to healthcare, and neighborhood safety significantly impact an individual's health. For example, a person with limited access to healthy food options may be at higher risk for chronic diseases.
Psychological and Emotional Well-being: Assess for stress, anxiety, depression, and coping mechanisms. Mental health is intrinsically linked to physical health; chronic stress can lead to physiological changes that increase disease risk.
Environmental Factors: Evaluate the patient's living and work environment for potential exposures to toxins, allergens, or pollutants.
Spiritual and Cultural Beliefs: Understand the patient's spiritual beliefs and cultural practices, as they can influence health decisions, dietary choices, and attitudes toward treatment.
Health Literacy: Assess the patient's ability to understand basic health information and make informed health decisions.