CLASS NAME: PRIMARY CARE ACROSS THE LIFESPAN III
ASSIGNMENT: CASE PRESENTATION “BACTERIAL VAGINOSIS”
NOT TO WRITER: MY CHOICE OF PRESENTATION TOPIC IS “BACTERIAL VAGINOSIS”. Below is what was done for patient at the clinic to help with the presentation.
Info of patient that I am using: 27 year old female with history of obesity and polycystic ovary syndrome. She presented to the clinic complaining of difficulty urination, itchiness to her genital area, blisters to genital area that are itchy and painful. She also reports she started having pain and itching after having sex with her boyfriend a week ago.
Family history: mother- essential hypertension, DM
GYN History
Reviewed GYN History
Date of Last Pap Smear: 07/25/2021
Obstetric History
Reviewed Obstetric History
TOTAL FULL PRE AB. I AB. S ECTOPICS MULTIPLE LIVING
0
Chief complains: Burning with urination, genital rash, vaginal complaints
Diagnoses: N76.0- Acute Vaginitis, Z72.51: High risk heterosexual behavior, A60.9: Anogenital herpesviral infection, unspecified, Z68.33: Body mass index [BMI] 33.0-33.9, adult
Orders: medication: fluconazole 150 mg tablet – Take 1 tablet(s) every day by oral route. Qty: (3) tablet, acyclovir 400 mg tablet – Take 1 tablet(s) every 8 hours by oral route.
Labs: URINALYSIS, DIPSTICK
PREGNANCY TEST, URINE
UA WITH CULTURE REFLEX
HSV 1/2 PCR
CHLAMYDIA/GC AMPLIFICATION-183194-P
HCV ANTIBODY RFX TO QUANT PCR
HIV AB/P24 AG WITH REFLEX
URINALYSIS, DIPSTICK
Results:
– Leukocytes: –
– Nitrite: –
– Urobilinogen: –
– Protein: +
– Blood: +
– Specific Gravity: 6.0
– Ketone: +
– pH: 5.0
PREGNANCY TEST, URINE
Result:
– HCG: negative
Assessment / Plan
1. Dysuria –
Patient reports pain that started a week ago after having sex. check pregnancy test, urine dipstick and Urinalysis. Pregnancy test negative. Urine dipstick postive for protein, blood and ketones. Results discussed with patient. Leukocytes negative.
R30.0: Dysuria
• URINALYSIS, DIPSTICK
• PREGNANCY TEST, URINE
• UA WITH CULTURE REFLEX
2. Bacterial Vaginosis –
Patient reports itchiness, tightness and pain to her gential area s/p unprotected sex about a week ago. patient says this sexual encounter was somewhat painful and 2 days later she feel the symptoms. . start fluconazole.
N76.0: Acute Vaginitis
• fluconazole 150 mg tablet –
Take 1 tablet(s) every day by oral route. Qty: (3) tablet Refills: 0 Pharmacy: FARMACIA DEL PUEBLO #2
3. Genital herpes simplex –
Patient reports that after having sex a week ago, she stated having pain and itching in her genital. Patient has been trying OTC suppository at home—herpetic blister observed on patients genitals/ inner labia majores. Start acyclovir. Check HSV- pending results and will review with patient in one month.
A60.9: Anogenital herpesviral infection, unspecified
• acyclovir 400 mg tablet –
Take 1 tablet(s) every 8 hours by oral route. Qty: (15) tablet Refills: 0 Pharmacy: FARMACIA DEL PUEBLO #2
• HSV 1/2 PCR
5. Unprotected sexual intercourse –
Patient reports having unprotected sex one week ago with her usual sex partner. Patient was educated on the impotence of using condoms during sex to decrease risk of sexually transmitted disease and unwanted pregnancy. Patient verbalized understanding. Check for chlamydia, hcv and hiv.
Z72.51: High risk heterosexual behavior
• CHLAMYDIA/GC AMPLIFICATION-183194-P
• HCV ANTIBODY RFX TO QUANT PCR
• HIV AB/P24 AG WITH REFLEX
6. Body mass index 30+ – obesity –
Current BMI 33.8 Healthy diet and exercise encouraged. Patient verbalized understanding. Will f/u
Z68.33: Body mass index [BMI] 33.0-33.9, adult
URINALYSIS, DIPSTICK
• Results:
– Leukocytes: –
– Nitrite: –
– Urobilinogen: –
– Protein: +
– Blood: +
– Specific Gravity: 6.0
– Ketone: +
– pH: 5.0
PREGNANCY TEST, URINE
• Result:
– HCG: negative
Introduction
Create a case presentation with PowerPoint slides related to a clinical encounter that you assessed during the practicum. Use Canvas Studio to record the audio and video portion of your presentation. Refer to the Start Here module for directions on how to record a presentation using Canvas Studio.
By the end of this assignment, you will:
• Support a diagnosis or treatment plan with scientific research, advanced concepts, quality care principles, and/or mathematics. (CO1 and CO2)
• Present a case that demonstrates your advanced skills in physical assessment, pharmacology, and therapeutic nursing interventions in the care of patients. (CO7)
• Analyze client outcomes to evaluate the effectiveness of treatment. (CO3)
• Identify the need for change in a patient’s healthcare plan that will either increase the effectiveness of the treatment, increase the safety of the treatment, and/or decrease the cost of the treatment without decreasing the treatment’s effectiveness. (CO5)
Instructions
I. Topic Selection
Begin your presentation by stating either:
• A diagnosis and treatment plan you made or witnessed during your practicum
• A healthcare service involving either health promotions, disease prevention, health protection, anticipatory guidance, or disease management that you provided or witnessed during your practicum
II. Research
Support this diagnosis or the provided healthcare service with:
• At least four references (for example, Buttaro, Grubbs, Bickley, and a medical journal)
• A research article
The research article should meet the following requirements:
• Supports the diagnosis and/or treatment
• Is no more than five years old
• Is qualitative or quantitative
• Describes the research study (for example, population, sample size, results, conclusion, and so on)
Your presentation must contain a slide detailing how the research article you chose and presented defends or supports the diagnosis and treatment or provided healthcare service.
III. Analysis
Analyze the outcomes to evaluate the effectiveness of the diagnosis and treatment plan or the healthcare service provided.
IV. Reflection
Identify how the treatment plan or healthcare service could have been altered in a way that either increased the effectiveness of the treatment, increased the safety of the treatment, and/or decreased the cost of the treatment without decreasing its effectiveness.
V. Posing Questions
At the conclusion of your presentation, pose two discussion questions for your classmates to answer.
VI. Citations
Include your references, in APA style, at the end of your presentation.
Assignment Guidelines
Your completed presentation must contain at least 15 slides and should span 15–20 minutes. Use Canvas Studio to record the audio and video portion of your presentation.
Use and cite at least four references (for example, Buttaro, Grubbs, Bickley, and a medical journal) and provide a research article pertaining to your final diagnosis. Your presentation must contain a slide detailing how the research article you chose and presented defends or supports the diagnosis and treatment. Include a References page in APA style at the end of your slideshow.
At the conclusion of your presentation, pose two discussion questions for your classmates. Submit your completed presentation to the assignment link provided and post it on the Case Presentation Discussion and Response board. Be sure to answer any questions posed by your colleagues.
Review the following requirements and resources before you begin to work on your case presentation:
• Research article should meet the following requirements:
o Supports diagnosis and/or treatment
o Is no more than 5 years old
o Is qualitative or quantitative
o Describes the research study (population, sample size, results, conclusion, and so on)
Case Presentation Rubric
Criteria Ratings
Introduction Greets audience; introduces self and interest in topic. Reviews objectives.
Discussion of topic with CC, subjective data, objective data (physical assessment), diagnosis, differential diagnosis, risk factors, treatment plan Discussion includes all required areas of content. Knowledge of topic is evident in organized presentation
Research article used to support diagnosis by student referencing and providing evidence on a slide. Also cites four additional resources in APA format. Supports diagnosis with research article provided, cites four additional resources, and has no errors in APA.
Conclusion and summary Conclusion and summary with recommendations; provides two questions for classmates.
Verbal presentation and professionalism Good eye contact and dialogue that flows and is easy to understand. Presentation is within time frame. Professional attire; presentation setting is not distracting.
Visual presentation No errors in spelling, vocabulary, or punctuation. Appropriate font size. At least 15 slides. Creative.
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