J.L. is a 32-year-old white female who presents to your clinic for…
Question Answered step-by-step J.L. is a 32-year-old white female who presents to your clinic for… J.L. is a 32-year-old white female who presents to your clinic for her annual exam and removal of her intrauterine device (IUD) so that she may begin trying to conceive. She is a G1P1 whose last pregnancy was 5 years ago. During that pregnancy, she developed gestational diabetes, which turned into Type 2 diabetes mellitus (T2DM) within one year of giving birth. She had a primary cesarean section due to fetal macrosomia. Since her diagnosis of T2DM, J.L. has had very good glycemic control and has lost about 25 lbs.PMH: Type 2 diabetes PSH: Primary cesarean sectionMEDS: Metformin ER 1000 mg dailySOCIAL HX: Married, lives with husband and 5-year-old son. Works from home doing medical transcription. She does not smoke or drink. ROS:General: Denies fever, chills, fatigueHEENT: Denies headaches, dizziness, visual disturbances, hearing loss, nasal congestion, sore throat, mouth lesions.Resp: Denies cough, congestion, SOA, wheezing.CV: Denies chest pain, palpitations.GI: Denies nausea, vomiting, diarrhea, abdominal pain, loss of appetite, hemorrhoids.GU: Denies urinary burning, urgency, or frequency, denies CVAT.Genital: Denies vaginal itching, discharge, odor.MS: Denies pain, limping, loss of strength.Psychiatric: Denies depression, anxiety, sleep disturbances.Neuro: Denies tingling, weakness, loss of sensation.Endo: Denies increased thirst, urination. PE:General Survey: well-developed, well-nourished 32 yo WF, in NADVital Signs: Ht 66″, Wt 173, BMI 27.9, BP 118/76, HR 78, RR 16, Temp.- 98.2 POSkin: warm, dry, intactHEENT: head normocephalic; eyes clear without drainage, PERRLA, ear canals clear bilat, tm with good cone of light; nares patent, mucosa pale-pink, no drainage present; no sinus tenderness, throat clear with no redness or exudatesNeck: supple, trachea midline, good ROMLymph Nodes: no swelling or tendernessThorax and Lungs: respirations even and unlabored, lungs CTATCardiovascular: S1S2, no murmurs, clicks, or rubsBreasts: soft, symmetric, no lumps or masses appreciable, no nipple discharge, no axillary adenopathyAbdomen: soft, sl round, BS present, non-tender, no hepatosplenomegalyGenitalia: minimal hair distribution due to shaving, labia majora and minora normal without lesions, no masses, lesions noted externally. Vagina: moist, pink, rugated with good tone. Normal, scant vaginal discharge noted, no odor. Lesions/masses absent. Cervix: pink, multiparous, non-friable without lesions. IUD strings present. Uterus: NSSC, mobile, non-tender, no masses, tenderness, or enlargement. Adnexa: non-palpable.Rectal: no external hemorrhoids present, internal deferredMusculoskeletal: Good ROM, steady gait, no apparent weakness or deficitsPsychiatric: clean, well-groomed, awake, alert, oriented, appropriateNeurologic: Reflexes: elicited, 2+ bilaterally view Questions:What other information is important at this type of visit?What is your plan of care for J.L. today?What tests or diagnostic would you consider today? Why?Would you pull the IUD? Why or why not?Would you prescribe any new medications? Discuss.Would you make any referrals? To whom?What counseling would you offer J.L. today? Health Science Science Nursing NURS 702 Share QuestionEmailCopy link Comments (0)
