History of the present illness
The patient is a 33-year older woman who comes to the urgent care center to seek medical attention following the extreme pain she experienced in front of her butt. The patient raises the issue of bad pain in front of her butt as the primary complaint.
History of the present illness
The patient is seen in the urgent care center complaining of bad pain in front of her butt. The patient reveals that the pain hurts to the extent that she cannot wipe her butt with a tissue after visiting the bathroom. The results on the physical examination of the patient reveals the following data;
HEENT: Unremarkable
CV: Unremarkable Don't use plagiarised sources.Get your custom essay just from $11/page
Respiratory: Unremarkable
Abdomen: Unremarkable
Temperature: 98.9 F
Pain level: 4/10 in a scale of 0-10
BP: 120/70HR 80 RR
Moreover, the external examination on the patient disclosed that the patient has typical hair distribution, intact urethral meatus, perineum with no redness or urethral discharge. Furthermore, the palpation result in the vagile opening revealed the information below;
Foul smell
Dark yellow discharge
Edema, along with the redness on the right side of the vagina.
Past medical history: The patient had no record of past medical history.
Surgical history: The patient denies any previous history
Family history: None of the family members of the patient has ever suffered from the condition experienced by the patient.
Social history: The patient reveals that she has a partner though they don’t engage in sexual activities.
Review of systems
Constitutional: Pain in the front part of the butt, dark yellow vaginal discharge and edema.
Respiratory: No respiratory distress.
Musculoskeletal: No muscle aches or weakness since the musculoskeletal examination is unremarkable.
Extremities: coloured vaginal discharge, edema together with redness on the right part of the vagina.
Based on palpation, all the systems associated with the patient’s subjective complain involve the dark yellow vaginal discharge, edema together with reddening of the right part of the vagina.
Assessment
Primary diagnosis
The patient has manifestations of Bartholin’s cyst. The chief complaint of pain in front of her butt is one of the clinical manifestations of Bartholin’s cyst. Furthermore, the report from palpation also indicates that the patient is likely to suffer from the disease. The foul smell and vaginal discharge are a clear indication of the presence of Bartholin’s cyst.
Pathophysiology
The primary gland infection or infected cysts is the primary cause of Bartholin’s cyst. Patients with the condition habitually complain of acute and rapidly progressive vulva pain, as evident in the case of BMW patients. The primary goal of physical examination and diagnosis is to identify any cause of the patient’s condition.
Differential diagnosis
The differential diagnosis on the patient’s condition encompasses genital warts, endometriosis and sebaceous cysts. Genital warts are the soft growth that habitually appear on the genitals.
Diagnostic tests
The appropriate test for the patient’s condition involves biopsy, which is usually performed to rule out vulvar cancer.
Therapeutic treatment
The patient’s condition may be treated by administering antibiotics to the patient. It can also be treated through marsupialization and sitz baths.
The patient was not appropriate for the NP as a provider because she had complicated symptoms that required collaboration with another health provider to offer a solution to the patient.
Education
The patient education available for the patient regarding her health condition involves proper hygiene and safe sex practices, which are useful in preventing Bartholin’s cyst.
Community resource
The available community resource for the patient is excision.
Referrals initiated
Once the patient has been discharged, she needs to see her gynecologists for the follow-up care on her health.
Target dates
The target date for re-evaluating the results of the plan and follow up should be three weeks.