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Women’s Health Case Study Assignment Dolores Sanchez is a…
Women’s Health Case Study Assignment
Dolores Sanchez is a 22-year-old female scheduled for a contraceptive visit. “I want to discuss birth control today. I have a boyfriend and have been using condoms for a while, but I want something more effective. Some of my friends use the shot and have gained weight. Will the pill make me gain weight?” Dolores states that she has been having intercourse on an infrequent basis over the past year. Now she has a steady partner and is having intercourse approximately twice a week for the past two months. Dolores states that she is currently having a regular, normal period that started 7 days ago and ended 2 days ago. Dolores goes on to say that although she has heard about birth control methods such as the implant and IUDs, her older sister uses the pill and likes the pill as a method. Dolores assumes that she, too, will do well with the pill.
Past Medical History: History of chlamydia (age 19)
Medication History: Ibuprofen 200 mg 2 tablets by mouth PRN for headaches and menstrual cramps: last dose 6 days ago
Drug Allergy: NKDA
Family Medical History: Mother: alive, age 40 (asthmatic, smoker), Father: alive, age 42 (HTN, hypercholesterolemia), Maternal grandmother: alive, age: 72 (breast cancer, treated with radiation), maternal grandfather: alive, age: 73 (lung problems, smoker), paternal grandmother: alive, age: 70 (hypercholesterolemia), paternal grandfather: deceased at age 69 (MI), Siblings: Two brothers: alive, age 14 and age 12; Sister alive, age 18, (all healthy)
Surgical History: Denies any surgeries or hospitalizations
Social History: Smokes one-half pack per day. She had her first cigarette at age 13. Had smoked infrequently until last year when she began to smoke regularly with her friends. Is a junior in college; enjoys college and maintains a B grade average. Is not involved in school sports and does not exercise regularly. She is very involved on campus in several organizations. Lives on campus in student housing – apartments. Her family is local and she goes to her family home several times per week to visit and to have dinner. Works part-time in a convenience store. Denies drug use; occasional beer with friends. CAGE questions: Negative responses. Uses seatbelts. Denies history of intimate partner violence.
Vaccination: She has had all of the usual childhood immunizations: MMR, Hepatitis B, varicella, IPV, HIBPCV13, DTaP series as a child, and Tdap booster at age 11. She started the HPV series with the first dose given one year ago. She did not return for subsequent doses.
Review of Systems:
General: denies recent weight loss or weight gain, no fever, no chills
HEENT: denies vision loss, denies hearing loss, Ear infections as a child but not since age 10; denies asthma, hay fever, frequent colds, nasal discharge, sinus problems; no dental problems, but does not have regular preventive dental care.
Cardiovascular: No history of heart murmur or heart problems. Denies chest pains or palpitations. Denies edema.
Respiratory: Denies any difficulty with breathing, asthma, or bronchitis. Denies cough or wheezing.
Abdominal/Gastrointestinal: Denies heartburn, abdominal pain, constipation, diarrhea, rectal bleeding; no history of liver or gallbladder disease
Genitourinary: Menarche, age 12; menses, regular 28- to 30- day cycles, lasting 5 days, describes flow as moderate for 3 days, lighter for 2 days; experiences cramping on day 1 of cycle for which she uses ibuprofen 400 mg 2 to 3 times a day for 1 day with relief of cramping; denies intermenstrual or postcoital bleeding or dyspareunia; first intercourse at age 15 ½; two sexual partners, infrequent intercourse until 2 months ago; no complaints of vaginal discharge, itching, burning, or urinary dysuria or frequency; LMP started 1 week ago, normal menses, has not had intercourse since LMP; is planning on becoming more sexually active with current partner
Neurological: Headache on first day of menses that is relieved by the ibuprofen; no other complaints of headaches, no history of migraines; no history of seizures
Endocrine: States she is fatigue on the three days a week that she works after class because she must stay up late to finish homework; is not fatigued if she has 8 hours of sleep at night; no history of diabetes
Musculoskeletal: No complaint; no history of injuries, muscle pain, or joint pain
Skin: Denies rashes or sores.
Psychiatric: Denies anxiety. Denies depression.
Physical Exam:
V/S: Temperature 98.2 F; BP 120/62 mm Hg Height: 66 inches Weight: 160 lbs. BMI 25.8
Gen: Alert, oriented, healthy appearing woman, in no acute distress. Well developed, hydrated, slightly overweight
CV: External chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and palpated at the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal. Normal S1& S2 present and are of normal intensity. No murmurs, gallops, or rubs auscultated.
Resp: Chest wall is symmetric and without deformity. No signs or respiratory distress. Lung sounds are clear in all lobes bilaterally without rales, rhonchi, or wheezes.
Abdomen: Soft, symmetric, non-distended, non-tender, bowel sounds + and normoactive x 4 quadrants, no masses palpated. No hepatomegaly or splenomegaly are noted.
Genital: External genitalia is normal in appearance without lesions, swelling, masses, or tenderness. Vagina is pink and moist without lesions. Presence of thin, gray, malodorous discharge in the vaginal canal. Cervix is non-tender without lesions or erosions. Uterus is anteflexed, non-tender and normal size. Ovaries are nontender without palpable masses or enlargement.
Neuro/Psych: alert and oriented X 3. CN II-XII grossly intact. Good eye contact, speech clear and goal oriented. Affect normal.
Skin: Normal, no lesions.
Diagnostic Tests: In-house: Microscopic exam of vaginal cells, wet-mount
Diagnostic Test Patient results
Microscopic Examination + clue cells
pH 5.0
Wet Mount Positive whiff-amine test
Case Questions:
What is/are the diagnoses? Support with literature evidence and interpretation of data presented in the case study.
Discuss the pathophysiology of the selected diagnosis.
Present and briefly discuss (rationale) 3 differential diagnoses for this patient.
Discuss plan of care for this patient-pharmacological, education, referral, and need for further diagnostic testing if any. Do not forget to include health promotion and address her primary reason for visit. Support your plan of care/interventions with literature evidence.
Reflect on the case presentation and the importance of accurate interpretation of subjective and objective data.
Give 2 or more references.
