Common Gynecologic Conditions
Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, diagnostic approaches, as well as to the development of treatment plans.
Raquel Rodrigue is a 22 -year-old Hispanic female presenting to the clinic for well exam. She is a full-time banker at Bank of America.
She reports history of Low Vit D, frequent UTIs, insomnia and tonsillitis. She had a tonsillectomy when she was 6 years old.
She takes AZO Cranberry 1 capsule QD, Vitamin D3 5,000 QD and Biotin 10,000 mg QD.
She has no medication, food or environmental allergies. She is allergic to latex.
Family history is non-contributary.
She drinks two to three glasses of wine 4 oz approximately every night to help her with her insomnia but on Fridays and Saturdays she enjoys drinking hard alcohol and having fun with her friends.
She smokes 1 of marijuana cigarette every weekend for relaxation and, according to patient, to prevent health issues.
Gyn history is onset of menses at age 11, menses every 28 days, lasting 3-4 days and using 6-7 pads. She reports some cramping during her menses and she uses Tylenol 500 mg PRN for her discomfort. She is currently using Yaz for birth control and reports no concerns about her contraception method or medication side effects. She does not use condoms because she reports that she is allergic to latex.
She reports that she likes to walk for 30 minutes 4 times a week, wears seatbelts when in the car and applies sunscreen daily. She reported that she enrolled in a dating site five months ago in hopes of finding a relationship that could lead to marriage.
Client complaint is that lately she has been feeling fatigue and several episodes of headaches with muscle aches. Sore throat and one lesion in her mouth, she stated that she believes she is experiencing these symptoms due to low vitamin D. She is mostly concerned about several pimple-like reddish ulcers in the perineum. She stated that she noticed one at first approximately two weeks ago and then a few others appeared and spread. She describes the ulcers to be uncomfortable with minimal, clear, odorless discharge, with occasional itching.
Vital signs during the visit:
Temperature 98.2, pulse 77, BP 128/76, height 5’5” and weight 138 lbs. BMI 23.0
General: Well groomed, well dressed, and well nourished
HEENT: Swollen glands, sore in right lower gumline
Lung: All lobes clear to auscultation, symmetric chest expansion.
CV: Regular rate and rhythm, S1S2 to auscultation, no murmurs, pulses palpable and equal bilaterally.
Breasts: fibrocystic changes bilaterally, no masses, no nipple discharge
VVBSU: whitish discharge, thin consistency, no odor noticed
Cervix: friable, no cervical motion tenderness.
Uterus: mid mobile, non-tender
Adnexa: without masses or cervical tenderness was noted.
Perineum: 4 small painless, reddish sores to right side of the perineum and labia, whitish discharge, no odor detected. The introitus was palpated and no cysts or abscesses were noted in the Bartholin glands. The cervix was pink and shiny with no significant discharge and no cervical motion tenderness.
PRIMARY DIAGNOSIS IS SYPHILIS; DIFFERENTIAL DIAGNOSES ARE HERPES SIMPLEX AND GENITAL WARTS
Based on your approved case study, post the following:
• Describe your case study
• Provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
• Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.
• Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.
• Also, share with your colleagues your experiences as well as what you learned from these experiences.
Use your Learning Resources and/or evidence from the literature to support your thinking and perspectives.