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OBGYN Pamela Flowers/Pamela Flowers – OBGYN

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OBGYN Pamela Flowers Pamela Flowers – OBGYN Pamela Flowers – OBGYN Diagnosis – Ectopic pregnancy DDX – Endometriosis, tubo-ovarian abcess, Pelvic inflammatory disease, ovarian cyst, ectopic pregnancy, abortion, ovarian torsion, dysmenorrhea-primary Problem Statement: ( Demographic description – chief complaint – Hx and PE key findings – risk factors ) Pamela Flowers is a 24 year old G0P0 woman presenting with abnormal vaginal bleeding and LLQ pelvic pain for 1 day. She has a history of dysparenuria on her left side. Gynecological exam shows tenderness and L- adnexal fullness (no mass) w/ enlarged + soft uterus. Patient has history of irregular periods. ( you just need a treatment plan ) CC: Pamela Flowers is a 24 year old G0P0 woman presenting with abnormal vaginal bleeding and LLQ pelvic pain HPI: The vaginal bleeding and pain started 1 day prior. Patient also describes dyspareunia 1 week ago, and has history of ‘irregular periods’ Meds: inhaler for asthma PMH: Pap smear + gyn exam 8mo ago normal – treated for chlamydia infection 3 years ago. SH: one currentsexual partner, condomsfor contraception. ROS: Only positive findings are seen in HPI Physical Exam: VS: Pulse – 104; BP – 108/60 RR – 14; T – 98.8F (37 C); SpO2 – 98% Gynecologic: Tenderness noted to bimanual exam. Left Adnexal fullness seen without mass. Uterusis enlarged and softened. ASSESSMENT/PLAN Test Results:


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Susan F Wilson, Jean Foret Giddens Health Assessment for Nursing Practice
Publisher: 2009 ISBN: 9780323053228 Edition: Unknown

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October 18, 2021
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