Caroline casey ihuman, Exams of Nursing

Download Caroline casey ihuman and more Exams Nursing in PDF only on Docsity! QUESTIONS AND ANSWERS Case Caroline casey ihuman TESTED AND CONFIRMED A+ ANSWERS ‘ ‘=. Caroline Casey 25 y/o 5' 6" (168 cm) 140.0 Ib (63.6 kg) Reason for encounter 25-year old who desires contraception Submitted on 08/19/2021 13:49:46 Case authored by: Ligaya V. Marasigan, MD PMH, FH, SH as Needed © Asked X Not asked Graded Approach Question Can you tell me about any current e PMH OF past medical problems you have had? Are you taking any over-the- © PMH counter oF herbal medications? e PMH Do you have any allergies? ‘Ave you taking any prescription © PMH x * SH Ave you using any form of birth ‘control? Review of Systems (ROS) Information Obtained Response iis tind The only problem | have ever had was a DVT. I had that a couple of months before | became pregnant. | was taking a new third generation birth contro! pil..you know the combination type. f developed a swollen sore lt call ‘and they used ultrasound and said | had a clot. They thought it was due to my birth control pil and a long car ride | had taken with my husband to visit hes tamity Just Tylenol, occasionally. Not to any drugs, but I'm allergic to latex, um... allergic to strawberries, and to kiwis too. Un...ne, Yes. Select the major body systems that have not been touched on during the interview process for the HPI. © Asked X Not asked information Obtained Graded Question Response Cliaie N Have you noticed any bruising, @ bleeding gums, nose bleeds, or other Uh..no. sites of increased bleeding? ‘Do you have problems with heat or @ [iid intolerance, increased thiest, 4, Increased sweating, frequent urination, of change in appetite? Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, of tremor? ‘Do you have any problems with an Itchy scalp, skin changes, moles, thinning hair, or britle nails? Do you have any problems with nervousness, depression, tack of interest, sadness, memory Joss, or mood changes, or ever hear voices ‘of See things that you know are not there? Uh. Show Dialo 0. Cae  Do you have any problems with fatigue, difficulty steeping unintentional weight loss or gain, fevers, of night sweats’? When you urinate, have you noticed any pain, buming, blood, dificulty starting or stopping, dribbling, incontinence, urgency during day or hight, or any changes in frequency? ‘Do you have any problems with headsches that dant go away with aspirin oF Tylenol (acetaminophen), double or biurred vision, difficulty «with night vision, problems hearing, ar pain, sinus problems, chronic sore throats, or difficulty swallowing? Do you experience chest pain discomfort or pressure. pair/pressure/dizziness with exertion r getting angry; palpstations: decreased exercise tolerance; oF biue/coid fingers and toes? Do you experience shortness of breath, wheezing, difficulty catching your breath, chranic cough, or Sputum production? ‘Do you have problems with nausea. ‘vomiting, constipation, diarrhea, cotfee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, or bloating? Do you have problems with muscle or joint pain, redness, swelling, muscle cramps, joint stitiness, joint swelling or redness, back pain, neck ‘or shoulder pain, or hip pain? ete le} Just fatigue. Uh..no, ‘No joint problems. roa! reat]  Exams Feedback © Porformed Correctly suscuitate abdomen * You performed the simulation correctly auscullate heart ‘© You portarmed the simulation correctly. © Your documentation was correct. blood pressure breast exam A breast exam is part of a thorough physical examination. inspect skin overall Fatigue can be caused by a large number of things. Doing a generalized evaluation of the hat, skin and nails can provide insight info nutrition, endocrine and other system problems, palpate abdomen in the absiominal oxam one is looking for signs of organomegaly that might suggest either liver or splenic ‘etiologies that might explain the complaint of fatigue, In addition, point tendemess or masses would suggest other infectous, erosive or malignancies that might again explain the fatigue. pulse respication SpO, tomperature  Case Problem Statement Caroline Casey is # 25-year-old G1P 100 here to be evaluated for her fatigue (post-delivery) and to determine an ‘optimal “spontaneous” contraception approach. Her gon is now 9 months old and is being weaned off breast-feeding in {or her returning to work full time. Post-detivery (uncomplicated) she has a history of heavy-long periods, itferent from pre-pregnancy ones. Physical exam is remarkable for a uterine size of 9-10 weeks pregnant. PMH is signilicant tor DVT while on BCP.  Comparison to Case @Corect X Missed € Incorrect Choice Yours Graded Cardiovascular Endocrine Gastrointestinal Integumentary Musculoskeletal Neurological Genitourinary/Renal Respiratory Hematologic Lymphatic immune Psychologie ‘Sexuai/Reproductive Booogoo00o00o0gno Feedback Sexual/Reproductive ‘The patient seeks counseling on conception. She also is concemed about her long, heavy periods, so evaluation of her reproductive system post-pregnancy is appropriate, Hematologic Caroline has a history of a DVT while taking BCP. In addition she complains of fatigue. Fatigue is a general problem that could involve the hematologic system, 80 further consideration of this system is appropaate. Endocrine ‘The patient socks counseling about the change in har menstrua periods and her fatigue. Fatigue is such a general problem that looking for systemic causes is appropriate,  Your Differential Diagnoses Legend: @ Correct X Missed € Extraneous @ hypomyroidiamn @ uterine fibroids % pregnancy  ay et Feedback Diagnosis Anemia: The patient presents with fatigue, ane of the most common symptoms of anemia. The low ferritin levels and high Total fron Binding Capacity are consistent with iton deficiency. Because Caroline's nutrition is good, one should Jook for another reason tor the Iron deficiency. Although breast milk does contain iron (0.1 mg per cup), it cannot account for her entire iran store depletion, thus one should look for alternative sources of iran loss such as blood loss, Uterine fibroids: If the fibroid is near the uterine lining, it can be the cause of heavy uterine bleeding to the level to cause anemia, as we see in our patient. Thus, anemia is the diagnosis that needs to be confirmed but uterine fibroids may be the cause. Case Plan Management Pian 1. Anemia - the data suggests iron deficiency anemia possibly due to increased blood loss from heavy menstruation and breast feeding © Iron suppiementation * Folic acid supplementation a & neuroprotection approach for future pregnancies 2, Contraception - the contraception recommendation must take the following components into consideration prior DVT on thied generation combinational BCP Problem of heavy menstrual bleeding due to fibroids desire for "spontaneous" contraceptive method reversible as patent desires tuture children ® recommendation - Levonorgestrel releasing intrauterine device (IUD) This device would cause the endometrial ining to be thinner and decrease the amount of bload loss with each menstrual period, thus helping to more rapidly correct and maintain the iron deficiency anemia. # Minimizes risk of DYT *# Allows for spontaneity © counseling ‘« Ensure pationt is aware that if pregnancy is desired, it may take 3 months for the progestin to become reduced and the uterus ta be ready to accopt egg Implantation 3. Fibroids - counseling as to what finroids are, how they can result in menormhagia and impact tuture fertility was discussed. in addition there was a discussion on the approaches to their removal should infertty become an issue.  cr STs { Summary Case Summary Exercises Learning objectivi Attar completing this case, the student should be able to do the following: References * Can conduct a history and physical exam pertinent to this pationt’s clinical presentation, i.e. identity both the concern for contraception as wall as pursue the campiaint of fatigue and menorrhagias ‘* Demonstrate the ability to correlate this pationt's history with risk factors that would narrow the clinician's recommendation options for contraception, * Understand and can counsel patient on a the various forms of contraception covering their © machanism of action © efficacy * advantages © disadvantages and contraincécations * Can explain the approach for emergency contraception. Independent study: Students are encouraged to do some self-directed learning about fibroids, what they are, how they might impact fertility, and what are the approaches to thir removal. Contraception Pearis Itis important to know the factors that can assist in counseling @ patient an which form(s) at contraception might be best for her. These factors inckide: * level ot remembering to take action ° acP © Disphragm © Condom ‘duration of contraception desired history to sexually transmitted infections and/or risk of infections (muttiple partners) amount of vaginal bleeding medical conditions contraception side effects Patient Disposition Caroline was happy to know that there was a cause for her fatigue and immodiately started taking her prenatal iron pals again as we as folate and B12. in addition, she agrecd with getting the progestin-roleasing IUD in the hopes it would eventually reduce har menstrual bleeding. in her follow-up visit she was pleased to find her Hb had increased and she related she had more energy. She was still having heavy periods, but she understood that it might take a few ‘more months betors the fut! effect of the IUD on blood flow would be seen. She also stated she felt her sex-life had improved, Seer reeked