Case_study_gyn
nikkyvuCC: "I keep getting reoccurrence UTIs."
a year ago
25
files (5)RecurrentUTIsCASESTUDY2_USETHIS.docx
WOMENINSTRUCTION.pptx
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RecurrentUTIsCASESTUDY2_USETHIS.docx
Recurrent UTIs – 30-Year-Old--15521179'.CASE STUDY 2’’’
CC: "I keep getting reoccurrence UTIs."
S: JS is a 30-year-old Hispanic female, G1P1 with recurrent urinary tract infections (≥3 in the past 6 months). Symptoms include dysuria, frequency, and urgency without fever, flank pain, or hematuria. Sexually active, using spermicide-coated condoms. No history of kidney stones.LMP: 02/15/2025 (regular). Denies ACHES (no abdominal pain, chest pain, headaches, eye problems, or severe leg pain).
O: VS: BP 112/70, HR: 82. weight 150 lbs.General: Well-appearing, no acute distress. Abdomen: No CVA tenderness. Pelvic: No vaginal discharge, no lesions, urethral meatus non-erythematous. Urinalysis pending; urine culture sent for further evaluation.
A: Recurrent Urinary Tract Infections (UTIs)
P: Nitrofurantoin (Macrobid) 100 mg PO BID x 5 days Dispense: 10 capsules. Refills: 0 Take with food to reduce GI upset. Urine culture is pending to assess bacterial resistance. Increase hydration. Urinate after intercourse. Avoid spermicide-coated condoms. Use cranberry supplements. RTC in one week for urine culture results, medication adherence review, and possible adjustment of prophylactic therapy.
WOMENINSTRUCTION.pptx
OB/GYN EXAM- Case Study/SOAP “S”what does the patient SAY
- “CC” Chief Complaint
-use the patient’s own words, reason for visit, and duration of symptoms
“I have had discharge for 5 days” “I have had left sided pain for 3 days” “I missed my period” “I am here for my yearly exam”
-HPI should include:
Clear chronological development of the problem or reason for visit, including onset of symptoms (if any), duration, progression, amount, factors worsening or helping, treatments already tried, previous h/of similar sx?, effects on ADL, include relevant FH, pertinent positives and negatives etc…
Consider any and all interaction with your client a therapeutic interaction by permitting free expression of issues & concerns….use clear language…..try to have remained dress during interview…..
GP etc….G –NUMBER OF PREG/ P LIVE BIRTHS / TERM/PRETERM (28-36WEEKS)/ABORTIONS/LIVING CHILDREN
1
HPI: 19 yo Caucasian female G0P0, LMP 5/5/19, presents today with c/o vaginal discharge. Denies fever, chills, dyspareunia, dysuria, abdominal/pelvic pain. Reports abnormal discharge, white and “curd-like” x 1 week. Positive pruritus and irritation to external genitalia. No relationship to intercourse or menses. Changed laundry soap 2 wks ago. Menses regular, q.28 days, lasting 4-6 days with mild cramping. Denies recent antibiotic use. Reports 3 sexual partners within past yr. Current partner X 4 mos. Sexually active since age 15 with 6 lifetime partners. Last IC 2 wks ago with condom. Contraception – COC’s, denies ACHES. States regular use of condoms.
ACHES – abdominal pain, chest pain, headaches, eye problems, swelling (and or aching in legs, thighs)
2
GYN HEALTH HISTORY “S”
OB/GYN HISTORY:
1. Menstrual History: LMP, PNMP, PMP
Menarche
Length of cycle
Average # of days of menses, regular?
Characteristics of flow?
Accompanying symptoms
(Normal cycle: 21-35 days, lasting 4-7 days)
Menopause?
“S”
2. Pregnancy History:
GTPAL
G(gravida), T(term), P(preterm), A(abortion), L(live)
G42113
CHRONOLOGICAL order: year, duration, type of birth, sex, weight, complications, is the child alive and well?, SAB’s?, ETP’s,? Ectopics, etc…
3. STI History: type of infection?, what tx?, how many?, complications?, screen for HIV risk – number of current sexual partners, lifetime partners, condom use? Does she douche?
Gravida – total number of pregnancy’s regardless of outcome – current preg included in count
Para – total number of births to > 20 weeks gestation regardless of outcome
4
“S” continued….
GYN problems or procedures:
Breast biopsies? Laparoscopy? D&C?
Paps:
Date of last (if ever)
Abnormal PAP’s ?, if so, follow-ups? HPV results?
Colposcopy’s, LEEP’s ?
Contraceptive use: currently using a method? Satisfied with method? Discuss her past methods if relevant to visit…
Menopause or peri menopause ? HRT?, non-pharmacologic therapies?
WOMEN’S HEALTH CASE STUDIES – GUIDE
4 total – see scheduled dates
HISTORY
S: CC: Use pt’s words in quotation marks
HPI: Include onset, duration, progression, timing, amount, aggravating factors, alleviating factors, treatments already tried, previous h/o similar S&S? Fully describe, e.g. pelvic pain, noting relationship in time with menstrual cycle, association with sex, tampon use, or other factors. Describe any vaginal bleeding not associated with menses. Include pertinent negatives. Do not repeat “patient states” over and over again…
OB/Gyn History:
Menstrual history: LMP, age at menarche, length of cycle, average number of days of menses, characteristics of flow, regularity of cycles, descriptions of any irregularities and/or accompanying symptoms. (Normal cycle: 21 – 35 days, menses last 4 – 7 days)
Pregnancy history: GTPAL. Chronological order: year, duration, type of birth, sex, baby’s weight, complications, is the child alive and well? TABs, SABs, ectopics, molar pregnancies.
S:
History of STIs: what type of infections, what tx, how frequently, complications? & screen for HIV risk. Number of current sexual partners and lifetime, condom use? Does she douche?
GYN problems or procedures:
Breast biopsies?
Paps:
Date of last (if ever)
Abnormal PAP’s ?, if so, follow-ups? HPV results?
Colposcopy’s, LEEP’s ?
Contraceptive use: currently using a method? Satisfied with method? Discuss her past methods if relevant to visit…
Menopause or peri-menopause ? HRT?, non-pharmacologic therapies?
S:
GENERAL PMH
PAST HOSPITALIZATIONS OR SERIOUS INJURIES
SURGICAL HISTORY – list in date order
IMMUNIZATION STATUS Tdap? HPV? Etc
Current Medications (OTC, herbal, prescription?)
Allergies: meds, environmental, latex, shellfish, iodine etc….
FMH: Include any pertinent to the CC or that would affect treatment plan (alcoholism, cancer esp reproductive, endocrine, genetic/chromosomal, hematological, mental retardation, CVD, congenital anomalies, GI, lung, neuro, renal, multiple gestation, etc..can use a genogram).
S:
Social History/Habits: Include use of tobacco, drugs, ETOH. Current living situation. Occupational, exposure to hazards. Relationships, recent sexual history/partners, monogamous?
Chart Review: Relevant information from chart, place either in S or O
____________________________________________________________________
ROS – as per your prior case studies with emphasis on Breast and GU
For ex – Denies breast tenderness, nipple discharge or noted changes in breast, does not perform monthly BSE etc…
PHYSICAL EXAM
PE: Include only systems r/to CC. Organize by systems and list in head to toe order. Sometimes no exam is necessary, and this should be noted (e.g., “deferred, not examined”) BULLET FORMAT
O: Vital signs, weight, height, BMI
General: Observation of pt – is she anxious, nervous, in pain? If so, identify the behaviors she demonstrates. Does she look older than stated age? State of health (ex: malnourished, well-nourished, obese)? Can use NAD
HEENT: Normocephalic. EOMI. PERRLA. TMs pearly gray bilaterally. No nasal drainage or lesions. Mouth and throat without lesions or exudates, teeth in good repair, gums pink.
Neck: No lymphadenopathy or thyroid enlargement, no masses palpated
(thyroid dysfunction can cause irregular menses, anovulation, and infertility)
Chest: CTAB No wheezes, rales, rhonchi
Heart: RRR, no murmur, S1S2
O:
Breast exam: Size (if remarkable, e.g. small, large, pendulous), nipples, symmetry. Skin changes (rashes, lesions, dimpling, retraction). Note masses, lumps, or tenderness. Description of a mass: Location (can draw picture or describe location as on a clock face), size, shape, consistency, mobility distinctness, nipple, skin over lump, tenderness, lymphadenopathy.
(Ex: No masses, lumps, or tenderness palpated, symmetrical without nipple discharge. Axilla without palpated masses or lymphadenopathy)
Abdomen: Obese, gravid, non-tender?, scars?,striae?, if pregnant or postpartum fundal height etc…. FHR?, fetal position? Etc etc….
O:
Pelvic exam:
External Genitalia: Mons including hair distribution ( no lesions, shaved), labia majora and minora, clitoris, Bartholin’s and Skene’s glands (often grouped with urethra as BUS), hymen, introitus, perineum. Piercings?
Please do not state “intact” – not appropriate terminology here
Vagina: Color, rugation, odor, tone, discharge. (Cystocele, rectocele (age appropriate), discharge, inflammation, lesions, masses)
(Ex: rugated, pink, no lesions or discharge, good tone)
Cervix: Color, os, position, texture, mobility. (Lesions, masses, inflammation, discharge, friability or bleeding, cervical motion tenderness/CMT)
(Ex: No CMT, lesions, ectropion, discharge, patent os (pinpoint, slit-like, stenotic)) Again, not “intact”
Uterus: Position, size, consistency, mobility. (Masses or tenderness)
(Ex: Small, firm, midline, smooth and mobile, non-tender)pregnancy = gravid with appropriate sizing
Adnexae: Size & shape. (Masses or tenderness) (Ex: bilaterally nontender, no masses palpated)
Rectal exam as appropriate to condition, age etc…
O:
Extremities: FROM no varicosities, or edema or if so please document appropriately - +1 pitting or non pitting…etc…
Neuro: as related to condition for ex, a pre-eclamptic patient would warrant a full assessment
Diagnostics: List results that you already have (lab, x-ray, urine dip, hCG,
wet mount etc…)
DIFFERENTIAL DIAGNOSES
A: Diagnosis: (CHOOSE YOUR WORKING DIAGNOSIS)
EX:
Undesired fertility (for gyn/birth control visit)
Prenatal visit at 32 weeks gestation
Vulvovaginal Candidiasis etc….
Cervicitis
Pathophysiologic support for your working diagnosis include pertinent positives and negatives
List and explain your next 2 differential diagnoses “what else could it be?” – you should have 2 additional DD’s related to your working diagnosis - list pertinent positives and negatives with a brief patho
YOU MAY HAVE OTHER DIAGNOSES – FOR EX
CONTRACEPTIVE MANAGEMENT
HIGH RISK SEXUAL BEHAVIORS
IUP @ 28 WEEKS
ETC……
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