For this Discussion, your instructor will assign you a case number.
Case 2
Cases
R.T. is a 35-year-old female patient who was seen in the clinic because she has been trying to get pregnant for about 7 months but she has not been successful.
Only positive gynecologic history for R.T. has been three episodes of pelvic inflammatory disease in the last five years.
Questions for the case
Discuss a diagnostic plan for R.T. and the rationale.
Discuss your presumptive diagnoses and ICD 10 number.
Develop the management plan (pharmacological and nonpharmacological).
Name some of the complications of PID.
Once you received your case number; answer the specific question on the table above. Then, continue to discuss the 3 topics listed below for your case:
Answer the specific question on the table above.
An effective health assessment incorporates not only physiological parameters; please suggest other parameters that should be considered and included on health assessments to reach maximal health potential on individuals.
Name the different family developmental stages and give examples of each one.
Describe family structure and function and the relationship with health care.
Submission Instructions:
Your instructor will assign you your case number and you will post on the case number you have been assigned.
You will reply to the other two case studies (One of each).
Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources
Diagnostic Plan for R.T.
R.T.’s history of pelvic inflammatory disease (PID) and her current difficulty in getting pregnant suggests that there may be underlying issues with her reproductive health. A diagnostic plan for R.T. should include a thorough history and physical examination, as well as laboratory and imaging tests to evaluate her reproductive system.
The first step in the diagnostic plan would be to perform a pelvic examination to assess for any abnormalities or signs of infection. This can include checking for cervical motion tenderness, adnexal tenderness, or cervical or vaginal discharge.
Next, laboratory tests such as a complete blood count (CBC), urinalysis, and sexually transmitted infection (STI) tests should be performed to rule out any underlying infections. Additional tests such as a pelvic ultrasound or hysterosalpingogram (HSG) can be used to assess the uterus and fallopian tubes for any abnormalities or blockages.
Presumptive Diagn and ICD 10 number
Based on R.T.’s history of pelvic inflammatory disease, a presumptive diagnosis of PID (ICD-10 code N76.1) should be considered. Additionally, it could be possible that infertility is due to tubal occlusion, tubal adhesions, or other pelvic abnormalities related to the past PID episodes and an infertility diagnosis (ICD-10 code N97.0) should be considered.
Management Plan
The management plan for R.T. should involve both pharmacological and nonpharmacological interventions.
Pharmacological interventions include antibiotics to treat any underlying infections and anti-inflammatory medications to reduce pain and inflammation. Hormonal therapy may also be considered if there is a hormonal imbalance.
Nonpharmacological interventions may include pelvic physical therapy, such as pelvic floor muscle exercises and relaxation techniques, to improve pelvic pain and discomfort. Additionally, counseling and support groups may be beneficial for R.T. as she navigates her journey towards pregnancy.
Complications of PID
PID can lead to a number of complications, including chronic pelvic pain, infertility, ectopic pregnancy, and increased risk of pelvic abscesses.
Effective Health Assessment
An effective health assessment incorporates not only physiological parameters, but also includes other parameters such as psychological and social factors, as well as the patient’s overall lifestyle. This includes, but is not limited to, assessing the patient’s mental health, current stressors, access to healthcare and support systems, and overall physical activity levels.
Family Developmental Stages
The first stage is the “Pre-family” stage, where individuals are single and not yet involved in a committed relationship.
The second stage is the “Forming a family” stage, where individuals are in the process of forming a committed relationship and may be considering marriage or starting a family.
The third stage is the “Family with young children” stage, where individuals are raising young children and managing the demands of parenting.
The fourth stage is the “Family with older children” stage, where individuals are managing the challenges of parenting older children and navigating the transition to empty nesters.
The final stage is the “Post-family” stage, where individuals are no longer raising children and may be dealing with issues related to aging and caring for aging parents.
Family Structure and Function
Family structure refers to the composition of a family, including the number of parents, children, and other relatives. Family function refers to the roles, responsibilities, and interactions within a family. The relationship between family structure and function and health care is that family can play an important role in the health and well-being
