Case Study 2

Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your clinic today to discuss contraceptive options.  She states that she is not interested in having more children but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs.  She has no known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Elaine has one older sister with no medical problems and one younger brother with no reported medical problems. 

• Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68 
• HEENT:  wnl 
• Neck: supple without adenopathy 
• Lungs/CV: wnl 
• Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge 
• Abd: soft, +BS, no tenderness 
• VVBSU: wnl, except 1^st degree cystocele 
• Cervix: firm, smooth, parous, without CMT 
• Uterus: RV, mobile, non-tender, approximately 10 cm, 
• Adnexa: without masses or tenderness 

Case Study Discussion: Gynecologic Health

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.

Photo Credit: Teodor Lazarev / Adobe Stock

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

By Day 3

Please POST your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions 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.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests you might recommend and explain why. Use your Learning Resources and/or evidence from the literature to support your position.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Learning Resources

Required Readings (click to expand/reduce)

Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.

• Chapter 10, “Women’s Health After Bariatric Surgery” (pp. 165 – 171)

Agency for Healthcare Research and Quality (AHRQ). Intimate partner violence screening: Fact sheet and resources. https://www.ahrq.gov/ncepcr/tools/healthier-pregna…

Fanslow, J., Wise, M. R., & Marriott, J. (2019). Intimate partner violence and women’s reproductive health. Obstetrics, Gynaecology & Reproductive Medicine, 29(12), 342–350. https://go.openathens.net/redirector/waldenu.edu?u…

Lockwood, C. J. (2019). Key points for today’s ‘well-woman’ exam: A guide for ob/gyns. Contemporary OB/GYN, 64(1), 23–29. https://search.ebscohost.com/login.aspx?direct=tru…

Clinical Guideline Resources

American College of Obstetricians and Gynecologists (ACOG). (2020). https://www.acog.org/

American Cancer Society, Inc. (ACS). (2020). Information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin. https://www.cancer.org/

American Nurses Association (ANA). (n.d.). https://www.nursingworld.org/

Centers for Disease Control and Prevention. (CDC). (n.d.). https://www.cdc.gov/

HealthyPeople 2030. (2020). Healthy People 2030 Framework. https://www.healthypeople.gov/2020/About-Healthy-P…

The American Association of Nurse Practitioners (AANP). What’s happening at your association. (2020). https://www.aanp.org/

Document: Focused SOAP Note Template (Word document)

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