week 4

NRNP 6552 Week 4 case study scenarios

Case #1. Debbie.

History of Present Illness (HPI): Debbie is a 19-year-old female G1P0010. She presents to your office as a

new patient for GYN visit. Her chief complaint is mild lower abdominal pain and a copious amount of

vaginal discharge that started a little over 1 week ago. She is sexually active and reports having four male

partners in the last six months.

Prior medical history: Depression, HSV-2. Prior surgical history: Surgical termination of pregnancy 1

year ago

Current medications: Lo loestrin Fe. Allergies: None

OB- GYN History: Surgical TOP x 1. Menarche age 9, cycle length- 7 days- frequency every 28 days- 3 -4

tampons per day. Hx of HSV-2. Never had pap smear.

LMP: 2 weeks ago – normal. Contraception history: OCP since TOP 1 year ago.

Social history: Lives parents. Denies ETOH or recreational drug use, never smoker. Graduated high

school. Not in college. Works FT as a waitress.

Family history: Mother - depression. Father – unknown

Review of Systems (ROS): Negative except as noted in HPI.

Physical Exam (PE)

VS: BP: 112/80, P: 72, RR: 16, T: 98.4, Weight: 110 lbs., Height 54 in, BMI 18.9 kg/m2

• General: WDWN female in NAD

• Abd: Soft, NT/ND, no masses/HSM

• GU: No external lesions, no erythema. Mucopurulent endocervical exudate visible in the

endocervical canal, sample obtained - cervix is friable. Mild CMT, no uterine tenderness, no

adnexal tenderness, no masses.

Case #2. Wendy.

History of Present Illness (HPI): Wendy, a 33-year-old woman, presents to the office with c/o of a 7-

month history of nipple discharge. She has noticed that her breasts are tender and both nipples produce

milky discharge on applying mild pressure. She has not noted any bloody or clear nipple discharge,

breast lumps, or skin changes. She also states she has not had a menstrual period for 7 months, and her

periods had been irregular for 8 months before they stopped altogether. Prior to her menstrual

irregularities, her menses occurred at a normal frequency and duration. She is sexually active with a

single partner and is trying to conceive.

Prior medical history: Headaches (past 6 months). Prior surgical history: None

Current medications: ibuprofen 400mg daily. Allergies: None

OB- GYN History: Spontaneous VD x 1. Menarche age 14, normal throughout life, until recent

complaints. No history of sexually transmitted infections (STDs). Last pap smear age 31 years, normal.

LMP: 7 months ago. Contraception history: None.

Social history: Lives with husband and 5-year-old son. Elementary school teacher. ETOH: 1-2 glasses

wine per month. No recreational drug use. Never smoked. Does not exercise. Last travel outside of the

country – Italy 8 months ago.

Family history: Mother - osteoporosis. Father (deceased age 80) – CVA

Review of Systems (ROS): General: Fatigue over the past 3 months; Skin – No rash, excessive facial hair

or acne; Gynecologic - Decreased libido. Vaginal dryness during sexual intercourse. She has been trying

to conceive for the last 2 years. One full-term, uncomplicated pregnancy 5 years ago; Neuro - 6-month

history of dull frontal and occasionally retro-orbital headaches that are increasing in frequency and that

now occur almost daily. There are no associated neurologic symptoms. She denies nausea, photophobia,

or phonophobia. Until 1 month ago, the headaches would resolve completely with ibuprofen, but for the

last month ibuprofen does not work. She denies history of headaches prior to 6 months ago.

Physical Exam (PE)

VS: BP: 133/68, P: 68, RR: 16, T: 97.3, Weight 134lbs, Height 64 inches, BMI 23 kg/m2

Breast - No breast masses or skin changes. No axillary lymphadenopathy. Mild diffuse breast tenderness

on palpation. Milky nipple discharge elicited bilaterally with pressure around areola.

Skin - Normal color, no rash, hirsutism, or acne.

Neuro- Normal and symmetric motor strength and reflexes on extremities. Sensation grossly intact to

light touch. Cranial nerves 2 through 12 intact. Gait and balance normal.

Thyroid – no thyromegaly or nodules

Case #3. Randi.

History of Present Illness (HPI): Randi, a 22-year-old female, presents to the clinic with c/o of a 3-day

history of thick white vaginal discharge, intense vaginal itching, and dysuria. She reports she is sexually

active with 1 partner. No history of STI’s. She had a recent sinus infection and was on amoxicillin x 10

days.

Prior medical history: None.

Prior surgical history: None.

Current medications: Mirena IUD – inserted last year. Allergies: Sulfa

Social history: College student. Lives with mother. Denies smoking or recreational drugs. Vapes daily.

Family history: Mother alive and well. Father alive and well. Sister – diabetes: uses insulin pump

OB- GYN History: Menarche age 13, cycle length 5 days - frequency every 28 days. No history of

sexually transmitted infections (STIs). Never had a pap smear.

Review of Systems (ROS): As noted in HPI.

Physical Exam (PE)

VS: BP: 110/70, P: 109, RR: 17, T: 98.9, Weight: 132 lbs., Height 65 inches, BMI 22 kg/m2

• General: AAO x 3, pleasant.

• Gynecological: EXTERNAL EXAM: mild erythema, white clumpy discharge. SPECULUM/INTERNAL

EXAM: Cervix: normal appearance, no lesions, no bleeding, white discharge, no cervical

movement tenderness. UTERUS: normal size, shape, and consistency, normal mobility,

nontender. ADNEXA: no masses or tenderness bilaterally.

Case #4. Roberta.

History of Present Illness (HPI): Roberta, a 53-year-old mother of two children, presents to your clinic

with c/o vaginal dryness and low sexual desire. She went into surgical menopause at the time of a total

hysterectomy for leiomyomas 5 years ago. She took HRT for severe climacteric symptoms for 2 years,

which she discontinued 3 years ago due to breast pain and a fear of breast cancer. She states her sex life

before surgery was active and satisfying. After the hysterectomy, her desire diminished considerably,

although at first she was not too concerned about it. Lately, however, because of this lack of desire, she

now complains of quite a reduction in sexual activity which is also less satisfying. When she does have

intercourse, she experiences dyspareunia. She is now worried about it because it is affecting her quality

of life and negatively impacting her relationship with her husband.

Over this past year, she has had a mammogram and general blood tests which were all normal.

Prior medical history: Uterine fibroids. Prior surgical history: TAH 5 years ago

Current medications: None. Allergies: Sulfa.

OB- GYN History: NSVD x 2 (2014 and 2012). Menarche age 12, cycle length was 8 -10 days- frequency

every 21 days- heavy flow with clots - tampons 5-6/day.

LMP: 5 years ago. Contraception history: None

Social history: Lives with her husband and 2 children. Works as an attorney. Denies EtOH, smoking, or

recreational drug use.

Family history: Mother – osteoporosis, thyroid disease. Father – prostate cancer. MGM – breast cancer

diagnosed at age 81 yo.

Review of Systems (ROS): Unremarkable with exception of as noted in HPI.

Physical Exam (PE)

VS: BP: 134/78, P: 58, RR: 16, T: 98.8 Weight: 144 lbs., Height: 65 inches, BMI 24

General Examination: Well developed, well nourished, in no acute distress.

Psych: alert and oriented, cooperative with exam, appears frustrated.

Abdomen: Soft, NTND, no masses

Gynecological: EXTERNAL EXAM: sparse hair distribution, pale and shiny – dry labia, no lesions, Mild

introital stenosis noted. SPECULUM/INTERNAL EXAM: Vaginal lining is thin and dry. Cervix: surgically

absent. UTERUS: surgically absent. ADNEXA: surgically absent.