For this Case Study Assignment, you will analyze a case study scenario to obtain information related to case 1. provided a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop treatment and management plans and complete chart attached.
HERE IS A CASE STUDY
Case #4. Nadine.
History of Present Illness (HPI): Nadine is a 22-year-old female G0 who presents for a well woman exam.
She is interested in starting birth control. She is sexually active with her boyfriend; they do not use
condoms.
Prior medical history: Sickle cell trait, Systemic lupus erythematosus (SLE), Pulmonary embolism,
Dysmenorrhea. Prior surgical history: None
Current medications: Plaquenil, Cellcept, prednisone, lisinopril, Eliquis, atorvastatin, omeprazole.
Allergies: None
OB- GYN History: Menarche age 12, cycle length-5 days- frequency every 28 days- 3 tampons per day.
History of chlamydia in the past year. Has received Human Papillomavirus (HPV) vaccine series.
LMP: 3 weeks ago. Contraception history: Withdrawal
Social history: Lives with her sister. Denies EtOH or recreational drug use. Vapes daily. Does not
exercise. Poor diet – fast food and sodas.
Family history: Mother alive – sickle cell. Father alive – HTN.
Review of Systems (ROS): Unremarkable.
Physical Exam (PE)
VS: BP: 133/68, P: 87, RR: 18, T: 98.2 Weight: 188 lbs., Height 64″, BMI 32.3
Lab – urine pregnancy test negative
General: Obesity in female. Oriented x 3. Pleasant.
Integumentary: Warm, dry, and intact.
Abdomen: Soft, NTND, BS present x 4.
External: Appropriate hair distribution, No lesions or erythema. Speculum exam: No discharge, no
lesions, no cervical motion tenderness (CMT). Bimanual exam: uterus normal size firm and non-tender.
No adnexal masses palpated bilaterally, nontender. Breast exam normal
Outline
Subjective data.
Identify data
provided in your
chosen case and
any additional
data needed.
Outline
Objective findings.
Identify findings
provided in your
chosen case and
any additional
data needed.
Identify
diagnostic tests,
procedures,
laboratory work
indicated.
Describe the
rationale for each
test or
intervention with
supporting
references.
Distinguish at
least three
differential
diagnoses.
Describe the
rationales for
your choice of
each diagnosis
with supporting
references.
Identify
appropriate
medications,
treatments or
other
interventions
associated with
each differential
diagnosis.
Describe
rationales and
supporting
references for
each.
Explain key
Social
Determinants of
Heath (SDoH)
for your chosen
case.
Describe
collaborative
care referrals
and patient
education needs
for your chosen
case.
Describe
rationales and
supporting
references for
each.
