Women Gynecologic Health Assignment

 Women Gynecologic Health Assignment

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To prepare:

• By Day 1 of this week, you will be assigned to a specific case study scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your case study assignment from your Instructor.
• Review the Learning Resources for this week and pay close attention to the media program related to the basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources.
• Carefully 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. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your SOAP note. This will help you develop your differential diagnosis and additional questions  Women Gynecologic Health Assignment

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Please post your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations. Your differential diagnosis, additional questions, additional diagnostic tests and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment

See the assignment tab for the week #3 discussion and post your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations. Your differential diagnosis, additional questions, additional diagnostic tests and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment. Review your colleagues’ initial responses.  Women Gynecologic Health Assignment

Case Study Scenario

Susan Spencer is a 38-year-old G5 P5 LC 6 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). Susan 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   Women Gynecologic Health Assignment

• 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

QUESTION:

What other information do you need for this case study?

Further information:

Susan relates to you that she has used birth control pills before but “would keep messing them up.”  After that, she switched to the patch, which she found worked well but discontinued use for reasons she does not remember. After that, she used natural family planning but still conceived her last two children unexpectedly.  She has had three partners in the last 12 months and has been with her current partner for the previous two months. She believes that he is “the one.” Women Gynecologic Health Assignment

Susan relates that her cycles come every 28-32 days, for 5-8 days, and on her heaviest day she must use a super tampon every hour and get up to change her pad 2-3 times at night. Her last GYN exam was one year ago and she shows you a copy of the results on her patient portal. The results for the pap were NILM, and HPV negative, and her cultures for GC/CT were negative.

In further questioning, you ask her about her migraines. She shares that these migraines occur just before her period, or when she’s stressed, and are preceded by a vision change in her right eye. She takes Excedrin Migraine for them and rests in a dark room until the migraine is done.

She has heard about a pill where she will only get her period four times a year and feels now that she’s older she can remember to take the pill daily and plans on putting a reminder in her phone.

QUESTIONS:

• What are your next steps/considerations?
• What teaching should you do?
• What methods are appropriate for Susan?

References: 

Schuiling, K. D. (2017). Women’s gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett Learning.  Women Gynecologic Health Assignment

• Chapter 11

Please use the Walden Library to research options and care for this patient. The resources should be from the last 5 years and be scholarly. NO WEB SEARCHES or public education sites may be used for citations in this course. This means: American Cancer Society, Web MD, Google etc. Our patients have access to this information and the research you do should be more advanced than a simple web search that anyone can do.

Class Resources:

• Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care(4th ed.). Jones and Bartlett Learning.
  • Chapter 10, “Women’s Health After Bariatric Surgery” (pp. 165 – 171)
• Agency for Healthcare Research and Quality (AHRQ). Intimate partner violence screening: Fact sheet and resourcesLinks to an external site.. https://www.ahrq.gov/ncepcr/tools/healthier-pregnancy/fact-sheets/partner-violence.html
• Fanslow, J., Wise, M. R., & Marriott, J. (2019). Intimate partner violence and women’s reproductive healthLinks to an external site.. Obstetrics, Gynaecology & Reproductive Medicine, 29(12), 342–350. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.ogrm.2019.09.003
• Lockwood, C. J. (2019). Key points for today’s ‘well-woman’ exam: A guide for ob/gynsLinks to an external site.. Contemporary OB/GYN, 64(1), 23–29. https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=134229869&site=ehost-live&scope=site&authtype=shib&custid=s6527200  Women Gynecologic Health Assignment

CLINICAL GUIDELINE RESOURCES

• American College of Obstetricians and Gynecologists (ACOG)Links to an external site.. (2020).  https://www.acog.org/
• American Nurses Association (ANA)Links to an external site.. (n.d.). https://www.nursingworld.org/
• Centers for Disease Control and Prevention. (CDC)Links to an external site.. (n.d.). https://www.cdc.gov/
• HealthyPeople 2030. (2020). Healthy People 2030 FrameworkLinks to an external site.. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework
• The American Association of Nurse Practitioners (AANP)Links to an external site.. What’s happening at your association. (2020). https://www.aanp.org/
• Document:Focused SOAP Note Template Download Focused SOAP Note Template(Word document)  Women Gynecologic Health Assignment

RUBRIC

PRAC_6552_Week3_Assignment2_Rubric

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