Walden University Health Conditions with Implications for Women Case Study

Case Study 2

Case Study: Dysfunctional Uterine Bleeding

Gretchen Abernathy is a 38-year-old G2P2002 Caucasian female who presents to the clinic with complaints of frequent menstrual bleeding. Her menstrual calendar shows bleeding frequency 17-36 days, lasting 5-10 days in duration and on her heaviest day she needs to change her super tampon every 2 hours. She relates this has been getting worse since stopping her OCP’s when she had a bilateral tubal ligation 4 months after having her second child 9 months ago. She is upset as no one told her that weight gain could happen after and relates she has gained 27 lbs. since her surgery. She states that all this bleeding is making her tired and she cannot keep herself awake. Gretchen’s mother told her she probably just had “low iron” and if she took vitamins, she would feel better.

• HEENT: wnl, hair dry, neck supple without adenopathy
• CV: RSR without murmur or gallop
• Lungs: clear to p&a.
• Abd soft, non-tender, BS all 4 quadrant.
• VVBSU: WNL
• Cervix: firm, smooth, parous, w/o CMT
• Uterus: mid mobile non tender, approximately 10 cm
• Adnexa: without masses or tenderness
• Extremities: negative homan’s, reflexes 2+ = bilaterally, no edema
• Case Study Discussion: Common Health Conditions with Implications for WomenCase 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, and diagnostic approaches, as well as to the development of treatment plans.Photo Credit: Dimco / Adobe StockFor this Case Study Discussion, you will propose a differential diagnosis with a minimum of 3 possible conditions or diseases. You will prioritize these diagnoses and explain which you would recommend.To prepare:By Day 1 of this week, you will be assigned to a specific scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.Review the Learning Resources for this week as well as Weeks 5 and 6 and specifically 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. Based on the case study scenario provided, complete a SOAP note and critically analyze this and focus your attention on the diagnostic tests. By Day 3Based on your assigned case study, post a Focused SOAP NOTE with the following:Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.Learning ResourcesRequired Readings (click to expand/reduce)Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.Chapter 17, “Breast Conditions” (pp. 337-349)Chapter 32, “Anatomy and Physiologic Adaptations of Normal Pregnancy” (pp. 677–673)Chapter 19, “Pregnancy Diagnosis, Decision-Making support, and Resolution” (pp. 367-379)General Guidelines for Health Screenings American Academy of Family Practice (AAFP). (2020). Browse AAFP clinical recommendations. https://www.aafp.org/home.htmlAmerican Cancer Society, Inc. (ACS). (2020). Cancer A-Z. https://www.cancer.org/Note: As you review this resource, select the “Cancer A-Z” topic in the navigation to review information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin.American College of Obstetricians and Gynecologists (ACOG). (2020). Clinical topics. https://www.acog.org/ Note: As you review this source, make sure to navigate to the “Topics” section in the navigation to review the clinical topics.HealthyPeople 2030. (2020). Healthy People 2030 Framework. https://www.healthypeople.gov/2020/About-Healthy-P…U.S. Preventive Services Task Force (USPTFS). (2017, September). Search and Filter All Recommendation Topics. https://www.uspreventiveservicestaskforce.org/usps…FNP Resources Centers for Disease Control and Prevention. (CDC). (n.d.). Disease & conditions. https://www.cdc.gov/DiseasesConditions/ The American Association of Nurse Practitioners (AANP). (2020). AANP practice: Clinical Resources, Business, acumen and opportunities for professional recognition. https://www.aanp.org/practiceGeriatric ResourcesNicholas, J. A., & Hall, W. J. (2011). Screening and preventive services for older adults. The Mount Sinai Journal of Medicine, New York, 78(4), 498–508. https://go.openathens.net/redirector/waldenu.edu?u…Document: Focused SOAP Note Template (Word document)Document: General Guidelines for Health Screenings Matrix 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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