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Juliana Mirabelles iHuman case study presents a unique set of challenges, requiring students to apply their knowledge and critical thinking skills to analyze complex medical scenarios. From understanding the patient’s history to conducting a thorough assessment and formulating an appropriate treatment plan, every step of the case requires careful attention to detail and clinical reasoning.
Juliana Mirabelles iHuman Case Study Sample
Juliana Mirabelles iHuman Case Study -CC Pain with urination is the presenting problem
Reason for encounter: Juliana Mirabelles, a 25-year-old heterosexual female, presents with complaints of burning during urination, vaginal discharge, and genital pain. She expresses concern about a potential bladder infection but notes differences from previous UTI symptoms.
History of present illness:
Juliana’s symptoms began three days ago, characterized by dysuria and yellow, mucousy vaginal discharge. She experiences relief with warm baths for dysuria but reports no improvement in discharge. Genital pain is rated 4/10 and worsens with urination. She also notes spotting during intercourse.
Review of systems:
Juliana denies weight loss, malaise, or night sweats. She has no vaginal itching or hematuria. On examination, she appears well-groomed and coherent, with pink, warm skin.Physical examination:
Juliana’s head and neck show no abnormalities, and her cardiovascular and respiratory systems are within normal limits. Abdominal examination reveals soft, non-tender areas with normo-active bowel sounds. Genitourinary examination reveals mucopurulent discharge from the cervical os and a friable cervix with a vaginal pH of 4.0.
Assessment/Plan:
Juliana is diagnosed with cervicitis due to culture-proven, uncomplicated gonorrhea. Pharmacologic management includes ceftriaxone 250mg (IM) single-dose and azithromycin 100mg (PO) twice daily for 7 days. Patient education emphasizes seeking prompt medical attention for worsening symptoms and practicing safe sex measures.
Follow-up:
Juliana is advised to follow up in one week or sooner if symptoms worsen. She is encouraged to avoid sexual intercourse until symptoms resolve and to use condoms for safe sex practices.
