Patient initial: S.L: Age: 24 Gender: Female Chief Complaint (CC):…

Question Answered step-by-step Patient initial: S.L: Age: 24 Gender: Female Chief Complaint (CC):… Patient initial: S.L: Age: 24 Gender: FemaleChief Complaint (CC): “Routine Care”History of Present Illness (HPI): 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. Medications: OTC PamprinAllergies: No known medication allergies.Past Medical History (PMH): NonePast Surgical History (PSH): NoneMenstrual History: Age of menarche 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributory. 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. O2SAT 100% (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. QUESTIONS:  What other information do you need? What testing would you perform/order? What are your initial thoughts for diagnosis?  Update: Susan relates she “sometimes” uses condoms but feels like she gets irritation from them. She does not desire pregnancy, but not sure what types of other options are available. She relates she has had 13 partners in the last 12 months; her partners have all been male except one in the past year. She has never received the Gardasil vaccine as her mother doesn’t believe it’s been tested enough and reports no history of STI’s but doesn’t remember being tested in the past. QUESTIONS: What are your next steps for a plan of care?  Subjective: What details did the patient provide regarding her personal and medical history?Objective: What observations did you make during the physical assessment?Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.Reflection notes: What would you do differently in a similar patient evaluation?IMPORTANT: For the Assessment and Plan sections, make sure you do not just list the differential and final diagnoses.  I want to see your clinical reasoning/rationale based on the information presented in subjective/objective. This clinical reasoning should be supported by scholarly evidence. Scholarly evidence includes peer reviewed journal articles from the Walden library and/or current clinical guidelines from reputable resources. Health Science Science Nursing NRNP 6552 Share QuestionEmailCopy link Comments (0)