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Gynecology Case Study

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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 diseases206(1), 6-14.

 

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