6552 wk 3 case study
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.
Task:
Please post your FOCUSED SOAP NOTE with your differential diagnosis.
Include the additional questions (additional questions ONLY related to the HPI/CC) 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.
Note: **Your differential diagnosis, additional questions, additional diagnostic tests and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment
Case Study:
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
FOCUSED SOAP NOTE:
Subjective: Elaine Goodwin, a 38-year-old female presents to the clinic for contraceptive counseling. She reports not wanting to have more children but mentions her partner has never fathered a child. No complaints of pain or discomfort reported.
Objective: Vital signs are within normal limits. Physical examination revealed a soft abdomen with + bowel sounds, no tenderness, 1st-degree cystocele. Uterus is retroverted, mobile, non-tender, approximately 10 cm. Cervix is firm, smooth, and parous without CMT. Adnexa is without masses or tenderness.
Assessment: Fibrocystic changes bilaterally in the breast.
Plan:
Provide counseling regarding contraceptive options, including the benefits and risks of each option.
Recommend a mammogram to rule out any possible malignancy due to fibrocystic changes in the breast.
Discuss the importance of routine cervical cancer screening and schedule a Pap smear.
Order a baseline lipid panel and fasting glucose test to assess cardiovascular risk.
Discuss lifestyle modifications for exercise-induced asthma and IBS.
Follow-up visit in 3 months to assess contraceptive efficacy and side effects.
Differential Diagnosis:
Fibrocystic changes in the breast.
Polycystic ovarian syndrome.
Endometriosis.
Hormonal imbalance.
Ovarian cysts.
Additional Questions:
When was your last menstrual period?
Have you experienced any irregular periods or abnormal vaginal bleeding?
Have you experienced any pain or discomfort during intercourse?
Have you noticed any changes in your bowel or bladder habits?
Have you experienced any significant stress or changes in your life recently?
Rationale:
Mammography will rule out any possible malignancy due to fibrocystic changes in the breast, which can be a concern in some cases. Cervical cancer screening is recommended to detect any abnormal changes in the cervix, which can lead to cancer if left untreated. A baseline lipid panel and fasting glucose test can help assess the patient’s cardiovascular risk, which is important to monitor due to her medical history of migraines and exercise-induced asthma. Lifestyle modifications can help manage the patient’s exercise-induced asthma and IBS symptoms, improving her quality of life.
The additional questions focus on potential gynecological and gastrointestinal symptoms that may provide further information for the differential diagnosis. The differential diagnosis includes various gynecological conditions such as polycystic ovarian syndrome, endometriosis, hormonal imbalance, and ovarian cysts, which can present with similar symptoms. Obtaining a thorough medical history and performing diagnostic tests can help rule out other issues or concerns and provide a proper diagnosis.
