Women’s Health Case Study

Women’s Health Case Study General Guidelines for Comprehensive Case Study You will complete the following case: Ms. K is an 18-year-old female first presents to her primary physician for a pre-college physical; age-appropriate immunizations and screen tests are reviewed. She is now returning 3 months with acute onset urinary frequency with associated dysuria, hematuria, and suprapubic pain, but no fever, chills, vaginal discharge, or vomiting and reports episodes of recent unprotected sexual intercourse with a new partner. Medications: currently on OCPs for BC PMH: unremarkable with a history of seasonal allergies, which she treats with OTC medications. PSH: wisdom teeth removed at age 17 under anesthesia in the dentist office. FH: Mother Alive and well with dx of DM and hypertension Father – alive and well with dx of HTN and obesity Brother – alive and well with no medical issues MGM – alive and well with hx of breast cancer, which she was treated for and not in Remission SH: By using the HEEADSSS approach, you learn the patient likes to go to movies, baseball games, and sometimes parties with her friends. At these parties there has been beer, and sometimes marijuana, which she tried once. She drinks beer once every few months, and has gotten drunk once. She does not smoke cigarettes. She has not had problems with sadness or depression. You then decide to move on to her sexual history. She lives in an apartment with 3 other roommates when attending college but then live at home with her family at other times. Physical Exam: Vital signs: Temperature is 36.2 C (99.0 F) Pulse is 88 beats/minute Respiratory rate is 18 breaths/minute Blood pressure is 110/60 mmHg Weight is 47.6 kg (105 lbs) Height is 63 in Body mass index is 18.6 kg/m2 Physical Exam General: Ms. K appears well, in no acute distress Cardiovascular: S1, S2 present with not murmurs, gallops or other arrhythmias noted. Pulmonary: Clear to auscultation A & P bilterally Skin: No visible lesions, but is warm to touch Back: No costovertebral angle (CVA) tendernes‌‌‌‌‌‌‍‍‍‍‌‍‍‌‌‌‌‌‌s noted Abdomen: Soft with active bowel sounds x 4 quads, with mild mid-line suprapubic tenderness. Percussion of the suprapubic region reveals no distention of the bladder. Pelvic: Examination of external genitalia reveals no ulcerations, redness, or other abnormalities of the skin, labia, introitus, or Bartholin glands. There is a small to moderate amount of white mucus in the vaginal vault. The cervix appears like a Strawberry with no discharge noted. The bimanual examination is without abnormalities. The uterus is midline, average-size, and not tender. There are no adnexal masses or tenderness, and there is no tenderness with cervical motion. LABS: Wet mount slides reveal no yeast, trichomonads, or clue cells. There are two to five white cells per high-power field. The pH of the vaginal discharge is 4.0. The whiff-amine test is negative. Urine dipstick: positive for leukocyte esterase, nitrites, and hemoglobin Pregnancy test: negative Chlamydia (CT) and Gonorrhea (GC) Nucleic Acid Amplification Testing (NAAT) – CT – positive; GC – negative After reviewing the case, you will present the case and supporting evidence in a PowerPoint presentation with the following components: Slide 1: Title, Student Name, Course, Date Slide 2: Summary or synopsis of Ms. K’s case Slide 3: HPI Slide 4: Medical History Slide 5: Family History Slide 6: Social History Slide 7: ROS Slide 8: Examination Slide 9: Labs (In-house) Slide 10: Primary Diagnosis and 3 Differential Diagnoses – ranked in priority Primary Diagnosis should be supported by data in the patient’s history, exam, and lab results. Slide 11: Management Plan: medication (dose, route, frequency), non-medication treatment, tests ordered, education, follow-up/referral. Slide 12-16: An evaluation of 5 evidence-based articles applicable to Ms. K’s case: evaluate 1 article per slide. Include title, author, and year of article Brief summary/purpose of the study How did the study support Ms. Pham’s case? Course texts will not count as a scholarly source. If using data from websites you must go back to the literature source for the information; no secondary sources are allowed, e.g. Medscape, UptoDate, etc. Slide 17: Reference List cite your sources in your work and provide references for the citations in APA format. Only references les‌‌‌‌‌‌‍‍‍‍‌‍‍‌‌‌‌‌‌s than 5 years old.

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