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? a. For the past Medical History?
b. For the Family History?
c. For the Psychosocial History?
d. For the Review of Systems?
The condition which may be suspected from the above presentation like heavy vaginal discharge and pelvic pain are
Bacterial vaginosis, vaginal yeast infection, pelvic inflammatory disease, yeast infection, vaginitis
Bacterial vaginosis is a bacterial over growth in , symptoms may include vaginal burning, abnormal vaginal discharge, vaginal odour
Vaginal yeast infection is the infection with yeast at vulva, this is presented with vaginal discharge, itching of vagina, pain during sex
Pelvic inflammatory disease is the infection of the female reproductive organs, presented with vaginal discharge, pelvic pain and pain during sex
Yeast infection is a fungal infection typically on the skin or mucous membranes caused by candida
Vaginitis is an inflammation that can result in discharge, itching and pain
Past history
Ask about any infection in the past, any reproductive complications, any medical history etc
Psychosocial history
The support she had from the family, family history, marital history, sexual history, menstrual history
Personal history and the premorbid personality also to be assessed
Review of the system
All the system examination including CNS, CVS, GIS, respiratory etc must be assessed
The reproductive system should be assessed thoroughly in a way of any other abnormalities in the examination.
Teresa Nguyen, a 28 yo Vietnamese American woman, is being seen in the clinic for the...