Patient 1
Assessment
ICD10-B37.3 Candidiasis of Vulva and Vagina
The causative agents of the candidiasis of the vagina are yeast-like fungi Candida albicans, Candida genus (Sissons, Borysiewicz, & Cohen, 2012). These fungi usually form part of the vaginal microflora. However, being an opportunistic infection, candidiasis develops when the pathogenic microorganism interacts with other environmental factors, e.g., immune malfunctions, exposure to infected objects, micro-impairments occurring during sexual intercourse. During the acute period of the disease, puffiness, and reddening of the vulva and vaginal mucosa, cracks, and abrasions can be observed (Maslyanskaya, Alderman, Louis-Jacques, & O’Brien, 2013). Grayish scurf, which is difficult to remove, can be found on the walls of the vagina. Usually, the vaginal discharge is represented as a dense, curdled white mass (sometimes with a greenish tinge) (Maslyanskaya et al., 2013). The patient’s symptoms are pruritus, burning, vaginal irritation, discharge, etc. − the common symptoms of the disease.
ICD10-N30.00 Acute Cystitis
The disease is characterized by the inflammation of the wall of the bladder (usually the mucous membrane). The common causative agents of cystitis are Escherichia coli, Staphylococcus, Proteus; the additional factors that cause inflammation may include detrusor-sphincter dyssynergia, fluctuations in the hormonal background, vaginal ectopia, etc. (Wessells, 2013) The major symptoms of cystitis are the increased frequency of urination, false urges to urinate, pain and burning during urination, change in the color of urine, cramping pain in the lower abdomen, and so on (Wessells, 2013). The patient shows such symptoms as burning sensations, pelvic pain, etc.
Education
Consumption of yogurts containing live lactic cultures, as well as natural products with a verified antifungal effect (e.g., garlic, propolis, hot red pepper,etc.), may help prevent the growth of fungi (Hassan, El-Kadi, & Sand, 2015). It is suggested to normalize weight, avoid the use of synthetic underwear, and casual sex (Hollier, 2016). A healthier lifestyle may help to control the hormonal background.
Referrals
No referrals.
Follow-Up Plan
Return in two weeks and repeat the analysis of the vaginal smear and urine.
Patient 2
Assessment
ICD10-M54.5 Low Back Pain
The major causes include back injuries or excessive muscle tension, compression of the nerve roots due to herniated disc, osteoarthritis, spondylolysis, and spondylolisthesis, etc. (Ebnezar, 2012). Arthritis-related lower back pain may be followed by stiffness and spread to the area of the hips (Ebnezar, 2012). The patient’s complaints include limited ROM, inability to walk erectly, and back tenderness.
Diagnostics
X-ray examination, CT, and MRI may help to establish a precise diagnosis. These methods help detect a serious problem (e.g., a herniated disc, a bone fracture, or cancer). They are usually implemented in case a patient is over 50 years old and has some congenital problems with the spine (Dagenais & Haldeman, 2012). The pain may be linked to gallstone disease and urinary tract impairments, e.g., infections or kidney stones. Therefore, the analysis of UTI (urinalysis or urine dipstick) is recommended. Blood analysis can be carried out to detect metabolic impairments, arthritis, cancer, or infection (Dagenais & Haldeman, 2012).
Education
The patient should take a rest in a comfortable position for a day or two by engaging in moderate activity (e.g., walking) every 2-3 hours for about 10-20 minutes (Dagenais & Haldeman, 2012). He may intake painkillers if necessary, e.g., acetaminophen. It can also be recommended to use a heating pad or taking warm showers (Hollier, 2016).
Referrals
The patient should address the physiotherapist for more specific recommendations regarding exercises for strengthening the muscles of the back.
Follow-Up Plan
Return to the clinic in two weeks with self-reports on changes in the health condition and effectiveness of treatment.
References
Dagenais, S., & Haldeman, S. (2012). Evidence-based management of low back pain. St. Louis, MO: Elsevier Mosby. Web.
Ebnezar, J. (2012). Low back pain. New Delhi, India: Jaypee Brothers Medical. Web.
Hassan, R., El-Kadi, S., & Sand, M. (2015). Effect of some organic acids on some fungal growth and their toxins production. International Journal of Advances in Biology, 2(1), 1-11. Web.
Hollier, A. (2016) Clinical guidelines in primary care. Scott, LA: Advanced Practice Education Associates. Web.
Maslyanskaya, S., Alderman, E., Louis-Jacques, J., & O’Brien, R. (2013). Vulvovaginal conditions. Oxford, UK: Blackwell Publishing. Web.
Sissons, J. G., Borysiewicz, L. K., & Cohen, J. (2012). Immunology of infection. London, UK: Academic Press. Web.
Wessells, H. (2013). Urological emergencies: A practical approach (current clinical urology). New York, NY: Humana Press. Web.