Common Health Conditions in Women Paper
Common Health Conditions in Women Paper
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. Common Health Conditions in Women Paper
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.
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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. Common Health Conditions in Women Paper
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.
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). 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). 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.
- Grid View
- List View
| Excellent Point range: 90–100 |
Good Point range: 80–89 |
Fair Point range: 70–79 |
Poor Point range: 0–69 |
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| Main Posting:
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. |
40 (40%) – 44 (44%)
Thoroughly responds to the discussion question(s). Post includes approprite diagnoses including explanations of appropriate diagnostic tests and treatment options. Incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources, with no less than 75% of post the post having exceptional depth and breadth. Supported by at least 3 current credible sources. |
35 (35%) – 39 (39%)
Responds to most of the discussion question(s) Post includes approprite diagnoses with explanations of appropriate diagnostic tests and treatment options. Somewhat incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources with no less than 50% of the post having exceptional depth and breadth. Supported by at least 3 credible references. |
31 (31%) – 34 (34%)
Responds to some of the discussion question(s). Post contains incomplete or vague diagnoses or explanations of appropriate diagnostic tests and treatment options. Is somewhat lacking in synthesis of knowledge gained from the course readings for the module and current credible sources. Post is cited with fewer than 2 credible references. |
0 (0%) – 30 (30%)
Does not respond to the discussion question(s). Post contains incomplete diagnoses or explanations of appropriate diagnostic tests and treatment options, or diagnoses and/or explanations are missing. Lacks synthesis gained from the course readings for the module and current credible sources. Contains only 1 or no credible references. |
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| Main Posting:
Writing |
6 (6%) – 6 (6%)
Written clearly and concisely. Contains no grammatical or spelling errors. Further adheres to current APA manual writing rules and style. Common Health Conditions in Women Paper |
5 (5%) – 5 (5%)
Written concisely. May contain one to two grammatical or spelling errors. Adheres to current APA manual writing rules and style. |
4 (4%) – 4 (4%)
Written somewhat concisely. May contain more than two spelling or grammatical errors. Contains some APA formatting errors. |
0 (0%) – 3 (3%)
Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style. |
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| Main Posting:
Timely and full participation |
9 (9%) – 10 (10%)
Meets requirements for timely, full, and active participation. Posts main discussion by due date. |
8 (8%) – 8 (8%)
Posts main discussion by due date. Meets requirements for full participation. |
7 (7%) – 7 (7%)
Posts main discussion by due date. |
0 (0%) – 6 (6%)
Does not meet requirements for full participation. Does not post main discussion by due date. |
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| First Response:
Post to colleague’s main post that is reflective and justified with credible sources. |
9 (9%) – 9 (9%)
Response exhibits critical thinking and application to practice settings. Responds to questions posed by faculty. The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives. |
8 (8%) – 8 (8%)
Response has some depth and may exhibit critical thinking or application to practice setting. |
7 (7%) – 7 (7%)
Response is on topic, may have some depth. |
0 (0%) – 6 (6%)
Response may not be on topic, lacks depth. |
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| First Response: Writing |
6 (6%) – 6 (6%)
Communication is professional and respectful to colleagues. Response to faculty questions are fully answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in Standard, Edited English. |
5 (5%) – 5 (5%)
Communication is mostly professional and respectful to colleagues. Response to faculty questions are mostly answered, if posed. Provides opinions and ideas that are supported by few credible sources. Response is written in Standard, Edited English. |
4 (4%) – 4 (4%)
Response posed in the discussion may lack effective professional communication. Response to faculty questions are somewhat answered, if posed. Few or no credible sources are cited. |
0 (0%) – 3 (3%)
Responses posted in the discussion lack effective communication. Response to faculty questions are missing. No credible sources are cited. |
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| First Response: Timely and full participation |
5 (5%) – 5 (5%)
Meets requirements for timely, full, and active participation. Posts by due date. |
4 (4%) – 4 (4%)
Meets requirements for full participation. Posts by due date. |
3 (3%) – 3 (3%)
Posts by due date. |
0 (0%) – 2 (2%)
Does not meet requirements for full participation. Does not post by due date. |
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| Second Response: Post to colleague’s main post that is reflective and justified with credible sources. |
9 (9%) – 9 (9%)
Response exhibits critical thinking and application to practice settings. Responds to questions posed by faculty. The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives. |
8 (8%) – 8 (8%)
Response has some depth and may exhibit critical thinking or application to practice setting. |
7 (7%) – 7 (7%)
Response is on topic, may have some depth. |
0 (0%) – 6 (6%)
Response may not be on topic, lacks depth. |
||
| Second Response: Writing |
6 (6%) – 6 (6%)
Communication is professional and respectful to colleagues. Response to faculty questions are fully answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in Standard, Edited English. |
5 (5%) – 5 (5%)
Communication is mostly professional and respectful to colleagues. Response to faculty questions are mostly answered, if posed. Provides opinions and ideas that are supported by few credible sources. Response is written in Standard, Edited English. |
4 (4%) – 4 (4%)
Response posed in the discussion may lack effective professional communication. Response to faculty questions are somewhat answered, if posed. Few or no credible sources are cited. |
0 (0%) – 3 (3%)
Responses posted in the discussion lack effective communication. Response to faculty questions are missing. No credible sources are cited. |
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| Second Response: Timely and full participation |
5 (5%) – 5 (5%)
Meets requirements for timely, full, and active participation. Posts by due date. |
4 (4%) – 4 (4%)
Meets requirements for full participation. Posts by due date. |
3 (3%) – 3 (3%)
Posts by due date. |
0 (0%) – 2 (2%)
Does not meet requirements for full participation. Does not post by due date. |
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| Total Points: 100 | ||||||
Name: NRNP_6552_Week8_Case_Study_Discussion_Rubric
Case Study Discussion: Common Health Conditions with Implications for Women
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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: Dimco / Adobe Stock
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: Common Health Conditions in Women Paper Submission and Grading Information. Common Health Conditions in Women Paper
Case Study 5 Case Study: Obstetrics
Scenario 2
Phillipa Hudson is a 29-year-old female presenting today at your clinic with a positive home pregnancy test. Her medical history is negative. Surgical history negative. Gyn history 1st menses age 12, with cycles coming every 28 days and lasting for 5 days. Her pap and std history are negative. She has been taking a woman’s gummy vitamin for the past year. Her OB history is
Date gestation outcome gender wt. anesthesia complications
1-2011 6 TAB None
4-2014 39 Low forceps delivery male 8’14” epidural Gestational diabetes
5-2016 8 weeks SAB
8-2016 35 weeks twins NSVD Female Female 6’6” 7’1” epidural Di/di twins
7-2017 38 weeks SVD male 8’10” local Gestational diabetes
Phillipa relates her last period (LMP) was 04-04-2022. She reports breast tenderness, fatigue, and nausea (which is what made her suspect she was pregnant). Common Health Conditions in Women Paper
