Case Study 2

Case Study: STI Investigation

Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full-time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / ETOH only on weekends, 6-8 hard liquor/ daily, and marijuana smoking. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has some cramping during her menses for which she takes otc Pamprin. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies.

Susan’s vital signs are taken and were temperature 97.8, pulse 68, BP 112/64, height 5’6” and weight 118 lbs. (which was the same as last year). BMI 19.04

• HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened.
• Lung: clear to auscultation
• CV: regular sinus rhythms without murmur or gallop
• Abd: soft, non-tender, liver normal,
• Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.
• VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
• Cervix: friable, some petechia no cervical motion tenderness.
• Uterus: mid mobile, non-tender
• Adnexa: without masses or tenderness
• Perineum: wnl
• Rectum: wnl
• Extremities: full rom, skin clear, no edema, reflexes 1+.

Neurological: CN II-12 grossly intact. Case Study Discussion: Common Gynecologic Conditions, Part 1

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.

Photo Credit: Teodor Lazarev / Adobe Stock

For this Case Study Discussion, you will once again review a case study scenario to obtain information related to a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop treatment and management plans.

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 assignment from your Instructor.
• Review the Learning Resources for this week 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 your Discussion. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your FOCUSED SOAP note. This information will help you develop your differential diagnosis and additional questions

BY DAY 3

Please POST your FOCUSED SOAP NOTE and post your primary diagnosis. Include the additional questions you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)

Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations.

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 diagnostic tests you would recommend and explain your reasoning. Use your Learning Resources and/or evidence from the literature to support your position.

Learning Resources

Required Readings (click to expand/reduce)

Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.

• Chapter 17, “Breast Conditions” (pp. 337-349)
• Chapter 18, “Alterations in Sexual Function” (pp. 353-364)
• Chapter 20, “Infertility” (pp. 383-398)
• Chapter 21, “Gynecologic Infections” (pp. 401-432)
• Chapter 22, “Sexually Transmitted Infections” (pp. 437-466)

Reproductive Health Access Project (2020). Your birth control choices. https://www.reproductiveaccess.org/wp-content/uplo…

Office of Women’s Health: Womenshealth.gov. (2017). Birth control methods. https://www.womenshealth.gov/a-z-topics/birth-cont…

Clinical Guideline Resources

As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for CDC – zika in pregnancy).

American Cancer Society, Inc. (ACS). (2020). Information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin. https://www.cancer.org/

American College of Obstetricians and Gynecologists (ACOG). (2020). https://www.acog.org/

American Nurses Association (ANA). (n.d.). Lead the profession to shape the future of nursing and health care. https://www.nursingworld.org/

Centers for Disease Control and Prevention. (CDC). (n.d.). https://www.cdc.gov/

HealthyPeople 2030. (2020). Healthy People 2030 Framework. https://www.healthypeople.gov/2020/About-Healthy-P…

The American Association of Nurse Practitioners (AANP). (2020). https://www.aanp.org/

Document: Focused SOAP Note Template (Word document)