NRNP6552 week 3 Case Study Discussion: Gynecologic Health 2022

 

Week 3 Case Studies

 

Case Study 1

Charlene Baja is a 22-year-old G0 P0 L0 presents to the clinic today for burning and discharge for 1 week. She states her boyfriend recently found out he was positive for chlamydia. She denies any other partners besides him. ?Her medical history is?remarkable for anxiety and depression. ?Her surgical history?is unremarkable. Her social history includes social?alcohol, but she denies tobacco and any recreational drugs.? She has no known drug allergies and takes a multivitamin and Srintec daily for oral contraception. Her health history?reveals that her mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia. ?Charlene has one brother with no medical history.

· Height 5’ 5”?Weight?148?(BMI 24.6),?BP 132/68 P?62

· HEENT:? WNL

· Neck: lymph nodes grossly normal

· Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam

· Breast: normal breast exam

· Abd: WNL

· VVBSU: WNL

· Cervix: firm, smooth, yellow watery discharge in large amount present

· Uterus: RV, mobile,?non-tender

· Adnexa: WNL

Case Study 2

Elaine Goodwin is a 38-year-old G5 P5 LC 6?presenting to your clinic today to discuss contraceptive options.??She states that she is not interested in having more children?but her new partner has never fathered a child.?Her medical history is?remarkable for exercise-induced asthma, migraines, and IBS.?Her surgical history?is remarkable only for tonsils as a child. Her social history is negative for?alcohol, tobacco, and recreational drugs.? She has no known drug allergies and takes only vitamin C.?Hospitalizations were only for childbirth.?Family history?reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased?due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell).?Elaine has one older sister with no medical problems and one younger brother with no reported medical problems.? 

 

• Height 5’ 7”?Weight?148?(BMI 23.1),?BP 118/72 P?68? 
• HEENT:? wnl? 
• Neck: supple without adenopathy? 
• Lungs/CV: wnl? 
• Breast: soft, fibrocystic changes bilaterally,?without masses, dimpling or discharge? 
• Abd: soft, +BS, no tenderness? 
• VVBSU: wnl, except?1st?degree cystocele? 
• Cervix: firm, smooth, parous, without CMT? 
• Uterus: RV, mobile,?non-tender,?approximately 10 cm,? 
• Adnexa: without masses or tenderness? 

 

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Case Study 3

Charlene Baja is a 22-year-old G0 P0 L0 presents to the clinic today for burning with urination and fishy discharge for 3 days. She states she has a new boyfriend and they are having unprotected intercourse. She denies any other partners besides him. ?Her medical history is?remarkable for anxiety and depression. ?Her surgical history?is unremarkable. Her social history includes social?alcohol, but she denies tobacco and any recreational drugs.? She has no known drug allergies and takes a multivitamin and Srintec daily for oral contraception. Her health history?reveals that her mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia. ?Charlene has one brother with no medical history.

· Height 5’ 5”?Weight?148?(BMI 24.6),?BP 132/68 P?62

· HEENT:? WNL

· Neck: lymph nodes grossly normal

· Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam

· Breast: normal breast exam

· Abd: suprapubic tenderness

· VVBSU: WNL

· Cervix: firm, smooth, copious amounts of green discharge present

· Uterus: RV, mobile,?non-tender

· Adnexa: WNL

*microscopic evaluation of vaginal fluid (wet mount) shows trichomonas (motile organisms)

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Week 3 Announcement For this Case Study Discussion, you were previously given your assigned case studies for this week. You can find this under announcements and doc sharing. Review the case study scenario to obtain information related to a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop treatment and management plans. To prepare: • By Day 1 of this week, you will be assigned to a specific case study scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your case study assignment from your Instructor. • Review the Learning Resources for this week and pay close attention to the media program related to the basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources. • Carefully review the clinical guideline resources specific to your assigned case study. • Use the Focused SOAP Note Template found in the Learning Resources to support Discussion. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your SOAP note. This will help you develop your differential diagnosis and additional questions By Day 3 Please POST your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations. Read a selection of your colleagues’ responses

Explanation & Answer

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