Gynecology Case Study
Subjective Information
- Regarding the patient, her bowel sounds normal, she has no allergies to medication, and no one at her home has been sick.
- Also, her pain has been increasing steadily.
- Further, she does not have any known food allergies.
- Further, her breakfast is typically composed of eggs and toast, raisins, and oatmeal.
- She has not exercised since the pain started. The last bowel movement yesterday for her was “normal”.
- She holds a part-time job working in a dormitory kitchen.
- Her dad’s mother is alive, aged 77 and is in a healthy condition.
- She sees a dentist every six months, and there are no concerns.
- She feels very safe at home and in relationships.
- She gets an annual women’s health exam.
- She has no history of depression or anxiety.
Problem Identification and Prioritization – Complete problem list generated and rationally prioritized; no extraneous information or issues listed.
- Pain is a constant dull ache
- Light percussion over lower abdomen elicited
- Respirations 18 unlabored.
- Vaginal discharge described as yellow and odorous
Objective Information
- She takes ortho-norvum 1+ and does not take any other medications.
- Her skin is pale.
- Last bowel movement yesterday, “normal” for her, no change in color or consistency
Assessment (medical diagnosis and differential diagnosis with rationale for each differential)
- Probable: It is necessary to conduct a differential test for STIs.
- Possible: It is necessary to assess more for the possibility of syphilis, gonorrhea, and herpes because of the yellow discharge. However, more tests need to be done because discharge is a poor predictor of STIs (Mlisana et al., 2012).
- Doubt – There is a low chance that the patient has HIV because she has not experienced a loss of body weight.
Plan of care
- Giving the patient pain medication.
- Giving her medication for the yellow vaginal discharge.
Reference
Mlisana, K., Naicker, N., Werner, L., Roberts, L., Van Loggerenberg, F., Baxter, C., … & Ronacher, K. (2012). Symptomatic vaginal discharge is a poor predictor of sexually transmitted infections and genital tract inflammation in high-risk women in South Africa. The Journal of infectious diseases, 206(1), 6-14.