2 Candidiasis of vulva and vagina B373 Rationale A candidiasis infection is

2 candidiasis of vulva and vagina b373 rationale a

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2. Candidiasis of vulva and vagina (B37.3) Rationale: A candidiasis infection is caused by the fungus, candida. Symptoms include extreme itching, swelling, and irritation, along with thick, white, odorless, cottage cheese-like vaginal discharge, itching, burning, pain during sex, and soreness (Centers for Disease Control and Prevention [CDC], 2019). M.G. could be suffering from a candidiasis infection due to her complaints of a consistent discharge for the past few months. 3. Trichomonal vulvovaginitis (A59.01) Rationale: Symptoms of trichomonas vaginalis (TV) include vaginal discharge, dysuria, itching, vulvar irritation, and abdominal pain (Kissinger, 2015). A differential diagnosis of TV should be considered for any woman with abnormal vaginal discharge who is sexually active and does not use protection consistently (Kissinger, 2015). M.G. should be tested for STIs, considering she is sexually active with her boyfriend and does not always use barrier methods during sexual intercourse. Primary diagnoses: 1. Encounter for routine child health examination with abnormal findings (Z00.121) Rationale: M.G.’s exam was considered abnormal due to the findings of abnormal vaginal discharge. 2. Encounter for screening for infections with a predominantly sexual mode of transmission (Z11.3) Rationale: Hawkins (2016) indicates that the American College of Obstetricians and Gynecologists guidelines recommend performing STI testing on females who present with abnormal vaginal discharge after having unprotected sexual intercourse. In M.G.’s case a urine was obtained for a dipstick/culture and STI testing. 3. Encounter for screening for human immunodeficiency virus (HIV) (Z11.4) Rationale: In accordance with recommendations by the Centers for Disease Control and Prevention (2015), HIV screening should be performed annually for everyone 13 – 64 years of age. 4. Encounter for immunizations (Z23) Pediatric SOAP Note
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PLAN Plan: Vaccinations administered today per CDC (2019) recommendations include serogroup B meningococcal (MenB) vaccine and 2 nd dose of meningococcal conjugate (MenACWY) vaccine today. Education: Hawkins (2016) reiterates American College of Gynecology (ACOG) guidelines to educate as appropriate in regard to history and physical findings, including, but not limited to, vaccines, diet, exercise, smoking and alcohol use prevention, safe sex, STI testing, and general safety and these were all reviewed. Patient educated on safe sex practices. Patient encouraged to begin birth control to prevent unwanted pregnancies (patient refuses at this time). Patient advised that condom use is the best way to prevent future vaginal infections, STIs, and sexually transmitted blood diseases, such as HIV and hepatitis C. Patient educated on good vaginal hygiene such as using a mild soap to bath the perineal area and avoiding douching and baths (Hollier, 2016).
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