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Case Study For Health Conditions In Women Discussion

Case Study For Health Conditions In Women Discussion

Subjective Data

Chief complaint: breast tenderness, fatigue, and nausea

History of the presenting illness: Phillipa Hudson is a 29years old female who presented at the emergency department due to increased breast tenderness, nausea, and fatigue. Breast tenderness is associated with the increased size of the areola and increased local temperature. The patient has nausea in the morning with cravings for different food. She denies vomiting, abdominal pain, and diarrhea. The patient reports fatigue, light-headedness, and mood swings. She presents to the hospital with a home positive pregnancy test.Case Study For Health Conditions In Women Discussion

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Past medical history: the patient has a history of hospitalization during delivery and when she had two abortions. She denies having chronic diseases and blood transfusions.

Current medication: woman’s gummy vitamin supplements

Immunization: her immunization schedule is up to date. Her last influenza vaccine was three months ago.

Surgical history: she denies a history of minor and major surgical procedures.

Reproductive history: her menarche was at the age of 12 years with a regular 28days cycle with 5 days of moderate flow. She reports having the premenstrual syndrome. She has a positive history of use of combined oral contraceptives and implants in the past but is not on any contraception method. She has had one sexual partner, denies having sexually transmitted diseases, and engaging in anal intercourse. Her LMP was in 4/4/2022. She is para 3+2 with four living children. Her first pregnancy was 11 years ago and had a therapeutic abortion at 6 weeks with no complications. Her second pregnancy was 8 years ago, carried the pregnancy until 39weeks and the outcome was a male infant born vial low forceps delivery with epidural anesthesia, weighing 8’14”. The third pregnancy was 6 years ago and the patient had a spontaneous abortion at 8 weeks gestation. The fourth pregnancy was 6years ago, the outcome was Di/di twins two Females weighing 6’6” and 7’1” born vial normal spontaneous vertex delivery with epidural anesthesia at 35weeks. The fifth pregnancy was four years ago, the outcome was a male infant weighing 8’10”, born via spontaneous vertex delivery with local anesthesia. The patient reports gestational diabetes.

Social history: the patient is married and lives with her husband and children. She works as an accountant at a crediting company. She has studied up to the college level. She enjoys taking coffee, deep-fried fish and fries, and pastries. She smokes cigarettes with her husband in the evening. She takes alcohol occasionally. She uses safety belts when driving. She does not engage in physical exercise.

Family history: the patient is the firstborn in a family of three. Her siblings, parents, and grandparents are alive and healthy with no record of chronic diseases. She denies a history of asthma, mental illness, and cancer Case Study For Health Conditions In Women Discussion.

Review of systems

General: the patient denies weight loss, chills, rigors, and night sweating.

HEENT: the patient denies blurring of vision, loss of hearing, throat pain, running nose, and change in voice.

Respiratory system: the patient denies coughing, chest pain, difficulties in breathing, and wheezing.

Cardiovascular system: she denies dyspnea, dizziness, syncope, palpitations, and tachycardia.

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

Genital urinary system: the patient has mild abdominal cramping. she denies dysuria, polyuria, dyspareunia, hematuria, vaginal discharge, and vaginal bleeding.

Musculoskeletal system: the patient denies joint pain, a history of fracture, muscle spasms, and joint stiffness.

Neurological system: the patient denies numbness, muscle weakness, facial droop, and paresthesia.

Psychiatric: the patient has occasional mood changes. However, she denies anxiety, depression, and psychosis.

Objective Data

General: the patient is calm and oriented. She has no pallor, jaundice, cyanosis, and edema.

Vitals: her blood pressure is at 128/78mmHg, the temperature at 36.8, and the pulse rate at 78beats per minute, respiratory rate at 14beats per minute, MBI at 33kg /m2, and pulse oximeter at 99%.

Breast examination: the breast sits atop the pectoralis major and extends horizontally. There is an increase in the size of the breast and nipple with hyperpigmentation. There is increased vascularization of the breast. The nipples are everted and tender. The lobules and ducts are palpable. There is no mass and discharge.

Skin: the skin is smooth and oily. There are no wrinkles, stretch marks, and acne.

Abdominal examination: The abdomen is distended with no stretchmarks. The bowel sounds are present in the four quadrants. There is no shifting dullness and fluid thrills. The abdomen is soft with a palpable mass at the suprapubic region. There are no areas of tenderness in the abdomen. The hegar sign and Chadwick sign are positive. Case Study For Health Conditions In Women Discussion

Assessment

Differential diagnosis

  • Pregnancy
  • Ovarian cyst
  • Premenstrual syndrome

Pregnancy is the period in which a fetus develops in the woman’s uterus until the term for maturation and delivery lasting about 40weeks. To make the diagnosis of pregnancy, the burse should assess for symptoms of early pregnancy like nausea, fatigue, breast tenderness,  abdominal cramping, and slight vaginal bleeding (Paik, et al, 2022). The nurse also asses for contraceptive use, menstrual history, and previous pregnancies. This is the patient’s diagnosis because she has three months history of amenorrhea, pelvic pain, breast tenderness, nausea, and fatigue. Additionally, the patient has not been on the contraceptive method and has a positive home pregnancy test. The Chadwick and Hegar sign is positive upon examination.

Premenstrual syndrome is a predictable series of physical and emotional changes occurring days before menstrual flow. The patient presents with mood swings, cravings, fatigue, irritability, breast tenderness, nausea, constipation, and headache (Itriyeva, K. 2022)Case Study For Health Conditions In Women Discussion. The premenstrual syndrome occurs every month due to the change in cyclical hormones and chemical changes in the brain. The patient presents with similar symptoms; breast tenderness, mood swings, nausea, and fatigue. However, it is not the actual diagnosis because the patient has had a history of amenorrhea for three months.

An ovarian cyst is a fluid-filled pocket surrounding the ovary. It is common in women of reproductive age who have a history of previous pregnancies. The presenting symptoms are abdominal cramping, fatigue, amenorrhea, headache, breast tenderness, and acne (Kulathevanayagam, et al, 2022). Patients with ovarian cysts usually present with a positive pregnancy test. The risk factors are obesity, pregnancy, endometriosis, recurrent pelvic pain, and previous ovarian cyst. The patient has similar risk factors; positive pregnancy test, obesity, and history of pregnancy. However, it is not the actual diagnosis because the patient has no history of using fertility pills.

Plan

Diagnostic tests: repeat a pregnancy test to confirm the diagnosis. A pelvic ultrasound would help determine pregnancy and gestation by date, rule out follicular and corpus luteum cysts.

Treatment

The patient is to continue with the woman’s gummy vitamin to boost immunity during pregnancy.  The patient should start her antenatal clinic to check for hemoglobin levels, sexually transmitted diseases, systemic infections, and toxoplasmosis (Pati, et al, 2022)Case Study For Health Conditions In Women Discussion. The patient has a bad obstetric history because she has had two abortions, therefore, she should start her follow-up clinic. Initiate folate tablets to avoid the neuro tube deformity of the unborn baby.

 References

Itriyeva, K. (2022). Premenstrual syndrome and premenstrual dysphoric disorder in adolescents. Current Problems in Pediatric and Adolescent Health Care, 101187. https://doi.org/10.1016/j.cppeds.2022.101187

Kulathevanayagam, K., Gelson, E., & MacDougall, J. (2022). 112 Ovarian cysts and masses in childhood and adolescence. European Journal of Obstetrics and Gynecology and Reproductive Biology, 273, e47. https://doi.org/10.1016/j.ejogrb.2022.02.141

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Paik, K. C., Aschen, S. Z., Swistel, A. S., & Talmor, M. (2022). P55. PREGNANCY Associated Breast Changes After Nipple Sparing Mastectomy. Plastic and Reconstructive Surgery Global Open, 10(4 Suppl). https://doi.org/10.1097%2F01.GOX.0000828572.50472.e2

Pati, S., Puri, P., Sinha, R., Panda, M., & Pati, S. (2022). Profile of comorbidity and multimorbidity among women attending antenatal clinics: An exploratory cross-sectional study from Odisha, India. Journal of Family Medicine and Primary Care, 11(5), 1980-1988. doi: 10.4103/jfmpc.jfmpc_1855_21 Case Study For Health Conditions In Women Discussion

Case Study Discussion: Common Health Conditions with Implications for Women

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, and diagnostic approaches, as well as to the development of treatment plans.

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For 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 3

Based 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.

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 or treatment options your colleagues suggested and 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!

Submission and Grading Information