Case Study Of Gynecological Health Discussion

Case Study Of Gynecological Health Discussion

Patient Particular’s

Name: Elaine Goodwin

Age: 38years

Gender: female

Race: white

Subjective Data

Chief Complaint: “ can we discuss contraceptive options?”

History of presenting illness: Elaine Goodwin is a 38-year-old white female who came to the clinic to discuss contraceptive methods. She is not willing to have children but she recently married a man who has no children. She states that she wants an effective birth control method without adverse effects. She adds that her previous contraceptive methods; Implanon, combined oral contraceptives, and Depo injection made her lose weight, and have heavy intra-menstrual cycle bleeding, and headaches. Case Study Of Gynecological Health Discussion

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Current medication: vitamin C

Allergies: she denies food and drug allergies

Past medical history: she has exercise-induced asthma, migraines, and IBS. She has had hospital admissions during childbirth.

Surgical history: tonsillectomy in her childhood

Family history: Elaine Goodwin is the second child in a family of three children. Her father is alive with a history of basal cell skin cancer. Her mother I alive with a history of osteopenia and fibromyalgia. Her elder sister and younger brother have no reported medical problems. Her maternal grandmother is living with dementia and her maternal grandfather has COPD.

Social history: Elaine Goodwin is newly married. She has children from her previous relationship. she has a bachelor’s degree in accounting and is currently working as a banker. She enjoys reading novels, swimming, and riding bicycles. She takes healthy home-prepared meals. She uses seatbelts while in a vehicle and does not use a phone when driving or walking on a pathway. She denies the use of alcohol, tobacco, and other recreational drugs.

Psychiatric history: the patient denies anxiety attacks, depressive mood, post-traumatic stress disorder, and psychosis.Case Study Of Gynecological Health Discussion

Violence history: the patient denies episodes of personal and public attacks, cyberbullying, and sexual harassment.

Reproductive history: her menarche was at 15 years old. She has been having a regular 28days cycle with four days of moderate flow. Her last menstrual period was on 1/6/2022. She experiences mild lower abdominal cramping and breast tenderness during her menstrual flow. she has been using coitus interruptus with her current partner. She has three children born at term via spontaneous vertex delivery. She denies post-partum complications.

Sexual history: the patient is sexually active and engages in penetrative vaginal intercourse at least three times a week. She has had three sexual partners since her first encounter at the age of 20 years. She denies a history of sexually transmitted diseases, dysuria, hematuria, vaginal discharge, post-coital bleeding, and dyspareunia.

Review Of Systems

General: the patient denies fatigue, weight loss, chills and rigors, night sweats, and fever.

HEENT: The patient denies headache, blurring of vision, loss of hearing, running nose, throat pain, and neck swelling.

Respiratory system: she denies coughing, chest pain, wheezing, sputum production, tachypnea, and difficulties in breathing.

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Cardiovascular system: the patient denies palpitations, syncope, lower limb swelling, orthopnea, paroxysmal nocturnal dyspnea, and tachycardia.

Gastrointestinal system: the patient denies abdominal pain, heartburn, reflux, bloating, nausea, vomiting, constipation, diarrhea, and loss of appetite.

Genitourinary system: the patient denies dysuria, hematuria, polyuria, urgency, vaginal discharge, vaginal itchiness, and flank pain.

Neurological system: the patient denies facial droop, peripheral numbness, dizziness, muscle weakness, and changes in bowel control. Case Study Of Gynecological Health Discussion

Musculoskeletal: the patient denies muscle pain, joint pain, joint stiffness, and muscle spasm.

Lymphatics: the patient denies enlarged nodes, recurring infections, and splenomegaly.

Psychiatric: the patient denies low self-esteem, insomnia, anxiety, depressive mood, and psychotic disorder.

Endocrine system: the patient denies heat and cold intolerance, weight gain, stretch marks, sweating, and irritability.

Hematologic: she denies bleeding tendencies, easy bruising, and anemia.

Skin: she denies skin color change, itchiness, and rash.

Objective Data

General examination: the patient is calm and alert. He has no pallor, jaundice, dehydration, cyanosis, edema, or lymphadenopathy.

Vitals: her blood pressure is at 118/72mmHg, her pulse rate at 68beats per minute, weight 148Ibs, weight 5’7, BMI 23.1.

HEENT: the head is round with no scars and wounds. She has no conjunctivitis, ear discharge, post nasal drip, and swollen tonsil gland. Case Study Of Gynecological Health Discussion

Neck: the neck is supple with no adenopathy.

Respiratory systems: the chest wall has symmetrical expansion when breathing in. The chest wall has no mass or scars. There is a resonant percussion note and vesicular breath sounds. There is no tachypnea, rhonchi, stridor, and crackles.

Cardiovascular system: the heart is palpable at the 5th ICS. There are n parasternal heaves and thrills. The heart sounds S1 S2 is present without murmurs. The peripheral pulses are present with a regular rhythm and rate.

Abdominal examination: the abdomen is round with a normal contour, no mass, and no striae. The bowel sounds are present in the four quadrants. There is a tympanic percussion note at the abdomen. There is no shifting dullness and fluid thrills. The liver span is 1cm below the costal margin. There is no organ enlargement.

Breast examination: the breasts are soft with fibrocystic changes bilaterally, without masses, dimpling, and discharge.

Cervix: the cervix is firm, parous, and without cervical motion tenderness.

Uterus: she has retroversion of the uterus that is mobile, non-tender, and 10cm in size.

Adnexa: the adnexa has no mass, fluid accumulation, and tenderness.

VVBSU: within the normal limit but has a 1st-degree cystocele Case Study Of Gynecological Health Discussion

Diagnostic Tests

  1. Complete blood count to rule out systemic infections, and check the hemoglobin levels, and platelet levels.
  2. Pregnancy test to rule out pregnancy
  3. Thyroid function test to rule out hypothyroidism and hyperthyroidism
  4. Random blood sugar to check the glycemic control
  5. Lipid profile to rule out hypercholesterolemia
  6. Breast mammogram to rule out breast cancer
  7. Erythrocytic sedimentation rate to rule out chronic diseases

Assessment

Differential Diagnoses

  1. Fibrocystic breast disease
  2. Breast cyst
  3. Fat necrosis

Fibrocystic breast disease is a benign disease of the breast that presents with a lumpy texture of the breast, tenderness, and enlargement of the nodules before menstrual periods and gets better at the beginning of a new cycle. It is common in women between 30 to 50years old. Causes are fluctuating hormonal levels, fluid fill cysts, hyperplasia of the milk duct, and enlarged breasts lobules (Kohnepoushi, et al, 2022). This is the patient’s primary diagnosis because she is above 30 years old and experiences breast pain and tenderness during her menstrual flow. On examination, her breasts are soft with fibrocystic changes and no nipple discharge.

Fat necrosis is a non-cancerous breast lump that develops in the breasts from dead or damaged breast tissue. Causes of death or damage to the breast tissues are fine needle aspiration, biopsy, breast infection, smoking, obesity, old age, chemotherapy, and breast reconstruction (Lee, et al, 2021)Case Study Of Gynecological Health Discussion. The presenting symptoms are firm mass or lamp, bruising of the breast tissue, nipple discharge and inversion, thickening of the breast skin, and swollen lymph nodes. This is not the actual diagnosis because the patient neither has the symptoms nor the risk factors of the disease.

A breast cyst is a benign mass of the breast that causes a breast lump. It may develop on one or both breasts causing pain and discomfort. They appear naturally at all ages but are most common after 35years old (Berg, W. A. 2021)Case Study Of Gynecological Health Discussion. They change due to hormonal change in size, becomes sore, and feels tender, especially during menstrual flow. The actual diagnosis is made after histopathology by fine-needle aspiration, core needle biopsy, and mammogram. This is not the diagnosis because the patient does not feel a breast lump.

Plan

Contraception Counseling

The patient is well informed of contraception methods; coitus interruptus, implant, combined oral contraceptives, and depo injection. However, these are not effective methods for her because of the side effects she has had. I would recommend she use intra-uterine devices like copper T because it does not have hormonal effects on the body. They can last up to five years with no side effects like hypertension, deep venous thrombosis, obesity, and hyperglycemia (Herrera, et al, 2019). There are no drug interactions that lowers its effectiveness, unlike hormonal contraceptives. Intra-uterine devices may cause health menstrual flow and abdominal cramping (Ouyang, et al, 2019)Case Study Of Gynecological Health Discussion. it does not need regular weight, blood pressure, and blood sugar monitoring. The patient can withdraw the method when the need to conceive arise. It is not associated to ectopic pregnancies and

Pharmacology Treatment

  1. Ibuprofen 400mg PO three times daily for abdominal cramping and breast tenderness.

Reflection

Assessing the patient was a good learning experience for me. Fibrocystic breast changes are common in female adults and may cause cancer most of the time. However, all women need a regular mammogram to rule out or detect malignant breast tissue. In the future, I will be equipped with more information to make an appropriate diagnosis and order investigations. Women should be aware of the benign breast changes to ensure they do self-examination and a regular check for early diagnosis and treatment Case Study Of Gynecological Health Discussion.

 References

Berg, W. A. (2021). BI-RADS 3 on screening breast ultrasound: what is it and what is the appropriate management?. Journal of Breast Imaging3(5), 527-538.

https://doi.org/10.1093/jbi/wbab060

Herrera, A. Y., Faude, S., Nielsen, S. E., Locke, M., & Mather, M. (2019). Effects of hormonal contraceptive phase and progestin generation on stress-induced cortisol and progesterone release. Neurobiology of stress10, 100151. https://doi.org/10.1016/j.ynstr.2019.100151

Kohnepoushi, P., Dehghanbanadaki, H., Mohammadzedeh, P. et al. The effect of the polycystic ovary syndrome and hypothyroidism on the risk of fibrocystic breast changes: a meta-analysis. Cancer Cell Int 22, 125 (2022)Case Study Of Gynecological Health Discussion. https://doi.org/10.1186/s12935-022-02547-5

Lee, J., Park, H.Y., Kim, W.W. et al. Natural course of fat necrosis after breast reconstruction: a 10-year follow-up study. BMC Cancer 21, 166 (2021). https://doi.org/10.1186/s12885-021-07881-x

Ouyang, M., Peng, K., Botfield, J. R., & McGeechan, K. (2019). Intrauterine contraceptive device training and outcomes for healthcare providers in developed countries: A systematic review. PloS one14(7), e0219746. https://doi.org/10.1371/journal.pone.0219746

Elaine Goodwin is a 38-year-old G5P5006  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 

Main Posting: Case Study Of Gynecological Health Discussion

Response to the case study discussion questions includes appropriate diagnoses with explanations of appropriate diagnostic tests and treatment options as directed, is based on evidence-based research where appropriate, and is incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources.–

Excellent
Point range: 90–100 40 (40%) – 44 (44%)
Good
Point range: 80–89 35 (35%) – 39 (39%)
Fair
Point range: 70–79 31 (31%) – 34 (34%)
Poor
Point range: 0–69 0 (0%) – 30 (30%)
Main Posting:

Writing–

Excellent
Point range: 90–100 6 (6%) – 6 (6%)
Good
Point range: 80–89 5 (5%) – 5 (5%)
Fair
Point range: 70–79 4 (4%) – 4 (4%)
Poor
Point range: 0–69 0 (0%) – 3 (3%)
Main Posting: Case Study Of Gynecological Health Discussion

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Timely and full participation–

Excellent
Point range: 90–100 9 (9%) – 10 (10%)
Good
Point range: 80–89 8 (8%) – 8 (8%)
Fair
Point range: 70–79 7 (7%) – 7 (7%)
Poor
Point range: 0–69 0 (0%) – 6 (6%) Case Study Of Gynecological Health Discussion

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.

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.

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.

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?

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.