NP Gyn Case Study

Learning Goal: I’m working on a nursing discussion question and need an explanation and answer to help me learn.

Case Study

Charlene Baja is a 22-year-old G0 P0 presents to the clinic today for burning and discharge for 1 week. She states her boyfriend recently found out he was positive for chlamydia. She denies any other partners besides him.  Her medical history is remarkable for anxiety and depression.  Her surgical history is unremarkable. Her social history includes social alcohol, but she denies tobacco and any recreational drugs.  She has no known drug allergies and takes a multivitamin and Sprintec daily for oral contraception. Her health history reveals that her mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia.  Charlene has one brother with no medical history.

· Height 5’ 5” Weight 148 (BMI 24.6), BP 132/68 P 62

· HEENT:  WNL

· Neck: lymph nodes grossly normal

· Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam

· Breast: normal breast exam

· Abd: WNL

· VVBSU: WNL

· Cervix: firm, smooth, yellow watery discharge in large amount present

· Uterus: RV, mobile, non-tender

· Adnexa: WNL

For this Case Study Discussion, you will review a case study scenario to obtain information related to a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop treatment and management plans.

Create FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanation

three references

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