Analysis of Various Disease Symptoms

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 the development of treatment plans.
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.
To prepare:
• By Day 1 of this week, you will be assigned to a specific case study scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your case study assignment from your Instructor.
• Review the Learning Resources for this week and pay close attention to the media program related to the basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources.
• Carefully review the clinical guideline resources specific to your assigned case study.
• Use the Focused SOAP Note Template found in the Learning Resources to support Discussion. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your SOAP note. This will help you develop your differential diagnosis and additional questions
Please post your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions (additional questions ONLY related to the HPI/CC) 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 explanations. Your differential diagnosis, additional questions, additional diagnostic tests and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment
Please see the case study below for the Week 3 Discussion. This focused Case Study is to be completed this week. Be concise, thorough and use headings for your SOAP note. When answering the questions at the end of the scenario, please number them as they are in the scenario.
Case Study 1
Scenario 1
Charlene Baja is a 22-year-old G0 P0 L0 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 Srintec 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
QUESTION:
What other information do you need? 
MORE QUESTIONS:

1. Has she used or tried any treatments so far?
2. When did she find out about her partner’s positive chlamydia status?
3. When was her last gyn exam and what were the results of the tests?  
4. Has she had any STD testing in the past?
5. Is she concerned with any other STDs?
6. What are your next steps/considerations? 
7. What education should you provide?
8. What treatments are appropriate for Elaine?