Week 8 Women’s Health Case Study Marie is a 26-year-old nulligravida Caucasian woman complaining of spaced menses that occur every 3 months with intermittent cramping and pain above both hip bones.
She states that her periods began to become less often and lighter about 6 years ago.
Menarche is reported at age 13. She is currently married and reports unprotected intercourse several days a week for 1 year.
She took a pregnancy test yesterday and it was negative. She is teary today and concerned that she will never get pregnant.
Her height is 64 inches. She weighs 175 lbs. and her body mass index (BMI) is 30.
She reports a weight gain of 30 pounds in the last 2 years. In addition to her concern about the inability to conceive, she is requesting a dermatology referral for acne.
Assessment: What other information in terms of Anne’s health history and in your physical exam would you want to obtain specific to the concerns with Anne’s development?
History of Present Illness: What additional information is needed or would be pertinent to the present illness?
What other questions would you ask while interviewing this patient and family?
Review of Systems: What questions regarding signs and symptoms would be the most pertinent to obtain for the review of systems and why is it relevant to this patient (be specific about what information you are attempting to elicit)?
Physical Examination: Provide physical assessment findings.
What focused examinations would you perform, include the rationale as to why.
Be specific, state what test you are performing and what you are looking/listening/palpating for.
DO NOT state, “assess abdomen”. Break this down by body systems. Think of this as what are you looking for with this specific patient.
Diagnostics: What INITIAL diagnostic studies will you order?
Examples of diagnostics: are EKG, Imaging studies, and Laboratory Studies. What else will help you identify the diagnosis of the patient (rule in or rule out)?
Screening tools: Are there any screening tools you would like to administer (give rationale)?
Working Diagnosis: What diagnosis should be considered given the above-described symptoms and history?
Differential Diagnosis: Focused list of diagnoses (at least two) considered based on the patient’s presentation.
ARRANGE DIFFERENTIAL DIAGNOSES FROM MOST LIKELY TO LEAST LIKELY.
Clearly identify the primary diagnosis first. This should be a focused list of the most likely diagnoses based on the information provided.
Clinical Understanding: Discussion on why the primary diagnosis was chosen as the working diagnosis and why the other differentials were not chosen.
Per the grading rubric, include at least one physical and psychosocial concern related to the primary diagnosis.
Management and Treatment Plan: Based on the primary diagnosis, how will you proceed with management? What is the prognosis? Additional tests or referrals?
What medications will be prescribed: include dose, timing, duration, etc. … (as if you were writing the order for the drug).
Any additional interventions?
How are you going to educate this patient and family (about disease, medications, procedures, etc.)?
Follow-up plan?
How will you take into consideration patient/caregiver psychosocial concerns including socioeconomic status?
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