Reference no: EM133950548
Assignment
Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full-time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / EtOH only on weekends, 6-8 hard liquor/ daily, and marijuana smoking. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has some cramping during her menses for which she takes otc Pamprin. She jogs 3-4 times a week, wears seatbelts when in the car, and "occasionally" uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies.
Susan's vital signs are taken and were temperature 97.8, pulse 68, BP 112/64, height 5'6" and weight 118 lbs. (which was the same as last year). BMI 19.04
1) HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened.
2) Lung: clear to auscultation
3) CV: regular sinus rhythms without murmur or gallop
4) Abd: soft, non-tender, liver normal,
5) Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.
6) VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
7) Cervix: friable, some petechia no cervical motion tenderness.
8) Uterus: mid mobile, non-tender
9) Adnexa: without masses or tenderness
10) Perineum: wnl
11) Rectum: wnl
12) Extremities: full rom, skin clear, no edema, reflexes 1+.
13) Neurological: CN II-12 grossly intact.
Task
I. Subjective data: Identify data provided in this case and any additional data needed.
II. Objective findings: Identify findings provided in this case and any additional data needed.
III. Identify diagnostic tests, procedures, laboratory work indicated: Describe the rationale for each test or intervention with supporting references.
IV. Distinguish at least three differential diagnoses: Describe the rationales for your choice of each diagnosis with supporting references.
V. Identify appropriate medications, treatments or other interventions associated with each differential diagnosis: Describe rationales and supporting references for each. Get the instant assignment help.
VI. Formulates a treatment plan related to case studies based on scientific rationale, evidence- based standards of care, and practice guidelines. Integrates ethical, psychological, physical, financial issues and Social Determinants of Health in plan.
VII. Describe collaborative care referrals and patient education needed for this case. Describe rationales and supporting references for each.