Assignment #2 – Case Study
The purpose of this assignment is to assess your knowledge of the course content and relevant CPGs, and to assess how well you integrate that knowledge into a clinical situation, and to evaluate your critical thinking and scholarly writing skills as a student NP at the graduate level.
Assignment 2 is a three-part case study relevant to Units 3, 4 and 5. Provide rationale throughout your paper using evidence to back up all approaches to care and any relevant data points. Utilize clinical practice guidelines (CPGs) from Canadian sources whenever possible. Never use public information websites to guide your practice. Please use headings and sub-headings throughout, particularly to identify the 3 parts and the series of questions.
The assignment should be no longer than 3000 words, NOT including the references, title page, or appendices. An abstract is not necessary. Complete all parts of the case study within the paper: only the prescription and any tables and charts should appear in an appendix. Do NOT restate the entire case anywhere in your paper: assume the reader is familiar with the case. Please do not use point form as it must be written with full sentences. All tables and charts should be part of your appendices and NOT part of the body of your paper. By using critical thinking and summarizing, you must answer each question within the body of your paper. See the Assessment Overview for more details on form and APA. Review NURS000 on writing tips and citation.
You may wish to refer to the SOAP note reference in the Professional Development section of the Study Guide for all elements of planning and on how to make a proper medical diagnostic statement.
Integrating Rational Prescribing Principles:
In this assignment you will be asked to identify Therapeutic Objective(s) of the medication(s) you will be prescribing. The Therapeutic Objective can be defined as: What you want the medication to do for the client. It may include an immediate effect and/or a long-term effect, and there may be more than one (there usually is). Please be specific with your objective(s). When relevant, do not list more than 3 objectives. Think about the “big picture” including the patient’s current experience and his/her life plan.
PART 1
Review the following patient profile, then answer the questions below.
Name: Belinda M.
DOB: Feb 28, 2001
CC: Painful periods
Hx of CC: Painful periods for 4 years, getting worse.
Stays home from school on first two days of menses due to pain. Uses a hot water bottle on abdomen, and takes 2 extra strength Tylenol, both help somewhat. Menstrual losses heaviest on first two days then taper off; lasts about 5 to 7 days. Denies vaginal discharge between periods.
MHx:
G0P0. Regular periods – 28 day cycle. Menarche aged 12.
LMP 3 weeks ago
Allergies: None
Medications: None.
Immunizations:
Tdap, Hep B, Gardasil at age 15. Completed series.
Contracted varicella at age 3.
Completed regular childhood vaccinations as per schedule.
Annual influenza vaccine.
Surgical History: none
Screening:
Last eye exam 2016
Regular dental care with hygiene q6months
Last full periodic health assessment 3 years ago.
Functional Health Patterns:
Lives at home. Good relationship with parents.
Diet: All food groups. Snacks often.
Sleep: Sleeps 7-8 hours a day.
Substance use: non-smoker, drinks alcohol occasionally with friends (less than 8 drinks/month, no other recreational drug use.
Exercise: Walks to school. Plays ringette three times a week
School: B student. No problems.
New male partner x 1 month. Feels safe in this relationship but not sure she wants to keep seeing him.
ROS:
HEENT, CNS, CVS, Pulm, GI – no concerns.
GU: She has just become sexually active with her boyfriend. No contraception used and inconsistent condom user.
Denies dysuria, frequency, urgency.
Exam:
B/P 106/64; HR 60 regular; RR 14 and easy; T 37.0; BMI: 22
In no acute distress. Abdominal and pelvic exam normal.
Skin: mild acne, no hirsutism, hair pattern within normal limits.
——–
Using evidence-based rationale, address/discuss the following:
1a) List a maximum of 3 differential diagnoses, including the likely/working diagnosis. Provide rationale for only the likely/working diagnosis.
1b) Are there any Red flags? If so, please list.
2) Identify any risk factors pertinent to her chief concern.
3) Identify any risk factors that you would like to discuss both today and at a follow up visit. Note when you would advise her for a follow up visit.
4) Based on your likely/working diagnosis, list priority screening test or inquiries, lab work or diagnostic imaging you will order today.
5) Discuss your approach to her statement about her partner.
6) Based on your likely/working diagnosis, what medications will you recommend today? What are the therapeutic objective(s)? (Maximum 3). Include the instructions will you give Belinda about any medications you are prescribing. Please follow guidelines for prescription writing.
PART 2
Belinda is now 30 years old.
CC: breast lump
Hx of CC: Partner found lump in her left breast two weeks ago.
Allergies: none.
Medications: none.
Immunizations UTD.
LMP 10 days ago. G0P0
FHx:
Mother: Type 2 DM, hypertension, dyslipidemia, gout
Father: Died from metastatic colon cancer, aged 59
Brother: A&W
Sister: Celiac Disease
FHP:
Diet: No restrictions.
Exercise: walks occasionally
Occupation: High School Teacher
Sleep: 7-8 hours a night; naps on weekends
Relationships: Same-sex, in stable relationship x 5 years. Thinking of marriage.
Substance use: cigarette smoker: ½ ppd for 7 years, occ alcohol binges, no recreational drugs.
Regular dental care and eye exams.
ROS:
No concerns.
Denies headache, weight loss or gain in last 3 months, cough, mastalgia, nipple discharge, bra size changes, trauma to breast.
Physical Exam:
Anxious but in no acute distress.
B/P 140/85 HR 72 regular RR 18 T 36.8C BMI: 30.
HEENT: No lymphadenopathy. Thyroid not palpable.
CNS: Grossly normal.
CVS: Normal exam.
Chest: Clear to auscultation, respirations quiet and easy
Breasts: Firm, non-tender, fixed nodule approx. 2cm x 1cm in left breast at 11 o’clock position above the nipple. New tattoo noted to left breast positioned at 2’oclock above the nipple; slight erythema, no induration, slightly tender, warm to touch, non-suppurative. No axillary nodes or supraclavicular nodes palpable. Nipples normal, no drainage. No other skin changes.
GI: Normal exam: truncal obesity noted.
GU: Not examined.
Skin: Multiple tattoos. No lesions or rashes seen. Caucasian.
——-
Address the following questions and be sure to include evidence-based rationale:
1a) List a maximum of 3 differential diagnoses, including the likely/working diagnosis. Provide rationale for only the likely/working diagnosis.
1b) Are there any Red flags? If so, please list.
2) Identify any risk factors pertinent to her chief concern.
3) Identify any risk factors that you would like to discuss both today and at a follow-up visit.
4) Based on your likely/working diagnosis, list relevant screening test or inquiries, lab work or diagnostic imaging you will order today. Explain.
5) Based on your likely/working diagnosis, what medication(s) will you recommend today, if any? What are the therapeutic objective(s)?
PART 3
Belinda is 53 years old.
CC: Discomfort during intercourse
Hx of CC: Has been getting worse for about a year. Using lubricants without much relief. Avoiding sex with partner which is affecting their relationship. During the day, she sometimes experiences pruritis and painful irritation in her external genitalia.
Med Hx:
Menopause age 48. G0P0
Type 2 diabetes mellitus diagnosed at age 42.
Meds: Metformin 500mg BID; Lipitor 20mg daily, Ramipril 10 mg daily.
Allergies: None
Immunizations: tetanus, influenza up to date.
FHP:
Perineal discomfort not interfering with ADLs or work. Shares various sex toys with partner. Denies rough play.
No other relevant findings.
ROS:
CNS, CVS, RESP, GI, Skin: no concerns.
GU: Denies vaginal bleeding or discharge. c/o urinary frequency at times but without dysuria or urgency. Denies frank hematuria. Denies bladder incontinence.
Physical Exam:
In no acute distress.
B/P: 130/80 HR 80 and regular RR: 16 and easy, T: 37.0C BMI: 32
GU: Erythematous, dull vulvar mucosa, no discharge seen, no odor. Vaginal mucosa thin and bleeds easily with exam. No lesions, ulcers, or prolapse seen. Cervix unremarkable.
——-
Address the following questions and be sure to include evidence-based rationale
1) List a maximum of 3 differential diagnoses, including the likely/working diagnosis. Provide rationale for only the likely/working diagnosis.
2) Are there any tests, diagnostic imaging or screening procedures or questionnaires that you would consider today? (Do not address the management of her DM in this assignment).
3) Identify the therapeutic objective(s), then discuss your management plan, complete with evidence to support your plan of care.
4) Write a prescription for Belinda appropriate to treat the working/presumptive diagnosis and place it in an appendix. Please write a complete prescription according to the guidelines for prescription writing in your jurisdiction.
5) What is your follow-up plan, including the time interval? At this visit, what other specific information will you want to gather from Belinda
