Walden University Gynecologic Health Case Study

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

Case Study Discussion: Gynecologic Health

Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, diagnostic approaches, as well as the development of treatment plans.Photo Credit: Teodor Lazarev / Adobe Stock

For this Case Study Discussion, you will review a 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.

By Day 6

Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests you might recommend and explain why. Use your Learning Resources and/or evidence from the literature to support your position.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!Learning ResourcesRequired Readings (click to expand/reduce)Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning. Chapter 10, “Women’s Health After Bariatric Surgery” (pp. 165 – 171)Agency for Healthcare Research and Quality (AHRQ). Intimate partner violence screening: Fact sheet and resources. https://www.ahrq.gov/ncepcr/tools/healthier-pregna… Fanslow, J., Wise, M. R., & Marriott, J. (2019). Intimate partner violence and women’s reproductive health. Obstetrics, Gynaecology & Reproductive Medicine, 29(12), 342–350. https://go.openathens.net/redirector/waldenu.edu?u… Lockwood, C. J. (2019). Key points for today’s ‘well-woman’ exam: A guide for ob/gyns. Contemporary OB/GYN, 64(1), 23–29. https://search.ebscohost.com/login.aspx?direct=tru…Clinical Guideline Resources American College of Obstetricians and Gynecologists (ACOG). (2020). https://www.acog.org/ American Cancer Society, Inc. (ACS). (2020). Information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin. https://www.cancer.org/American Nurses Association (ANA). (n.d.). https://www.nursingworld.org/Centers for Disease Control and Prevention. (CDC). (n.d.). https://www.cdc.gov/ HealthyPeople 2030. (2020). Healthy People 2030 Framework. https://www.healthypeople.gov/2020/About-Healthy-P…The American Association of Nurse Practitioners (AANP). What’s happening at your association. (2020). https://www.aanp.org/Document: Focused SOAP Note Template (Word document) NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the
patient’s own words, for instance, “headache,” not “bad headache for 3 days.”
HPI: This is the symptom analysis section of your note. Thorough documentation in this
section is essential for patient care, coding, and billing analysis. Paint a picture of what
is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to
start every HPI with age, race, and gender (e.g., 34-year-old African American female).
You must include the seven attributes of each principal symptom in paragraph form, not
a list. If the CC was “headache,” the LOCATES for the HPI might look like the following
example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable
but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for
use. Also include over-the-counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a
description of what the allergy is (e.g., angioedema, anaphylaxis). This will help
determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major
illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
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NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
Soc & Substance Hx: Include occupation and major hobbies, family status, vaping,
tobacco and alcohol use (previous and current use, how many times a day, how many
years), and any other pertinent data. Always add some health promotion questions
here, such as whether they use seat belts all the time or whether they have working
smoke detectors in the house, the condition of the living environment, text/cell phone
use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic
illnesses. The reason for death of any deceased first-degree relatives should be
included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression).
History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual—
current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant
(gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used),
types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any
sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential
diagnosis. You should list each system as follows: General: Head: EENT: and so forth.
You should list these in bullet format and document the systems in order from head to
toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No
palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain
or blood.
© 2022 Walden University, LLC
NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or
polydipsia.
GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP:
MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?.
sexually active?
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head to toe, include what you see, hear, and feel when conducting your
physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and
history. Do not use “WNL” or “normal.” You must describe what you see. Always
document in head-to-toe format (i.e., General: Head: EENT:).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop
the differential diagnoses (support with evidenced and guidelines).
A.
Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your
primary or presumptive diagnosis should be at the top of the list. For each diagnosis,
provide supportive documentation with evidence-based guidelines.
P.
Includes documentation of diagnostic studies that will be obtained, referrals to other
health care providers, therapeutic interventions, education, disposition of the patient,
and any planned follow-up visits. Each diagnosis or condition documented in the
assessment should be addressed in the plan. The details of the plan should follow an
orderly manner. Also included in this section is the reflection. The student should
reflect on this case and discuss whether or not they agree with their preceptor’s
treatment of the patient and why or why not. What did they learn from this case? What
would they do differently?
© 2022 Walden University, LLC
NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
Also include in your reflection a discussion related to health promotion and disease
prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and
other risk factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based, peer-reviewed journal
articles or evidenced-based guidelines that relate to this case to support your
diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition
formatting.
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