NRNP-6552 - ADVANCED NURSE PRACTICE IN REPRODUCTIVE HEALTH CARE |
WALDEN UNIVERSITY
NRNP 6552: CASE STUDY - Week 3 Assignment 2
Latest Discussions 2023
Case Study 2
Case Study: STI Investigation
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 remarkablefor 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
weight118 lbs. (which was the same as last year). BMI 19.04
• HEENT: WNL except some anterior cervical adenopathy
bilaterally, and throatappears reddened.
• Lung: clear to auscultation
• CV: regular sinus rhythms without murmur or gallop
• Abd: soft, non-tender, liver normal,
• Breasts: fibrocystic changes bilaterally, no masses, dimpling,
redness or discharge, no adenopathy, and bilateral nipple
piercings.
• VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
• Cervix: friable, some petechia no cervical motion tenderness.
• Uterus: mid mobile, non-tender
• Adnexa: without masses or tenderness
• Perineum: wnl
• Rectum: wnl
• Extremities: full rom, skin clear, no edema, reflexes 1+.
• Neurological: CN II-12 grossly intact.
Patient Information:
S.L. 24-year-old Caucasian female
S.
CC: Postcoital bleeding, sore throat
,HPI: S.L. is a 24-year-old Caucasian female in for routine yearly exam.
Patient reports postcoitalbleeding for the past 6 weeks, sore throat for the
past 3 weeks, and constant vaginal burning and yellow discharge, pain when
urinating, and frequent urination x 3 weeks. She rates this as 4/10 scale. She
states that Tylenol does not relieve these symptoms. She has tried douching
to relieve the vaginal symptoms, but it always comes back. Reports a fever
for a day or two, relieved by OTC Tylenol. Patient thought it was allergies.
She is sexually active, does not use condoms. Has
had 2 sexual partners in the last month. She reports having an unremarkable
health history priorto the current symptoms. Denies chills, nausea, or
vomiting. She reports that neither partner is aware of the other and she
wants to keep it that way and wants it “fixed” as soon as possible.
Current Medications:
• OTC Pamprin 2 tabs po prn menstrual cramps.
• OTC Tylenol 500mg 2 tabs po prn.
Allergies: NKDA, none reported.
PMHx: No medical or surgical history to date. Reports being depressed and
anxious over hercurrent symptoms.
Surgical Hx: Denies prior surgical procedures.
Hospitalizati
ons: None
reported.
Preventative
Health
Immunizatio
ns:
• Influenza 10/2021
• Tuberculin skin test November 2021-negative
• SARS-CoV2 Moderna vaccine x 3 2021-2022
• Tetanus 2019
• Tdap series age 5-6
• Hep B series unk age.
• MMR series age 5-6
• Polio age 6
, • Varicella age 6
Social & Substance Hx: Patient reports she loves her job as a full-time
administrative assistant.She drives 15-20 minutes to work. She jogs 3-4
times a week, wears seatbelts when in the car, and “occasionally” uses
sunscreen. Patient lives at home in separate detached in-law apartment on
her parent’s property and reports feeling safe living there. She is the
youngest of three adopted children. 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.
Fam Hx: Family history is non-contributary, patient adopted.
Mental Hx: Reports occasional sadness and anxiety related to her
menstrual cycle. She deniessuicidal or homicidal ideations. Denies seeing
a therapist.
Violence Hx: Had one verbally abusive relationship at age 18. That person
is no longer in herlife.
Sexual/Reproductive Hx: Heterosexually active. G1P0, 1 abortion 2 years
ago. Menarche at age13; menses every 28-32 days, lasting 4-6 day and using
3 tampons daily. LMP: 3/01/22. She reports some cramping during her
menses for which she takes OTC Pamprin. States she has a satisfying sexual
life. She reports practicing vaginal and oral intercourse. Uses pull out
method. No condoms. Denies recent pregnancy.
ROS:
General: Reports general malaise. Reports having had a recent elevated
temperature relieved byOTC Tylenol. Denies chills, nausea, or vomiting. No
unintentional weight loss or gains.
HEENT: Head: denies headaches, vertigo, or trauma. Eyes: denies vision
loss, blurred vision, or double vision. Ears: denies hearing loss, ringing of the
ears. Nose: denies rhinitis. Throat: reports sore throat and swollen lymph
nodes.
Skin: Denies rash, itching, bruising.
Cardiovascular: Denies chest pain, palpitations, or history of heart disease.
Respiratory: Denies SOB, asthma, or breathing difficulties.
Breasts: Denies pain, nipple discharge or retraction.
Gastrointestinal: Denies nausea, vomiting, bloating, diarrhea, or constipation.
Genitourinary: Reports dysuria; vaginal burning, burning with
urination, and thick yellowdischarge.
WALDEN UNIVERSITY
NRNP 6552: CASE STUDY - Week 3 Assignment 2
Latest Discussions 2023
Case Study 2
Case Study: STI Investigation
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 remarkablefor 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
weight118 lbs. (which was the same as last year). BMI 19.04
• HEENT: WNL except some anterior cervical adenopathy
bilaterally, and throatappears reddened.
• Lung: clear to auscultation
• CV: regular sinus rhythms without murmur or gallop
• Abd: soft, non-tender, liver normal,
• Breasts: fibrocystic changes bilaterally, no masses, dimpling,
redness or discharge, no adenopathy, and bilateral nipple
piercings.
• VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
• Cervix: friable, some petechia no cervical motion tenderness.
• Uterus: mid mobile, non-tender
• Adnexa: without masses or tenderness
• Perineum: wnl
• Rectum: wnl
• Extremities: full rom, skin clear, no edema, reflexes 1+.
• Neurological: CN II-12 grossly intact.
Patient Information:
S.L. 24-year-old Caucasian female
S.
CC: Postcoital bleeding, sore throat
,HPI: S.L. is a 24-year-old Caucasian female in for routine yearly exam.
Patient reports postcoitalbleeding for the past 6 weeks, sore throat for the
past 3 weeks, and constant vaginal burning and yellow discharge, pain when
urinating, and frequent urination x 3 weeks. She rates this as 4/10 scale. She
states that Tylenol does not relieve these symptoms. She has tried douching
to relieve the vaginal symptoms, but it always comes back. Reports a fever
for a day or two, relieved by OTC Tylenol. Patient thought it was allergies.
She is sexually active, does not use condoms. Has
had 2 sexual partners in the last month. She reports having an unremarkable
health history priorto the current symptoms. Denies chills, nausea, or
vomiting. She reports that neither partner is aware of the other and she
wants to keep it that way and wants it “fixed” as soon as possible.
Current Medications:
• OTC Pamprin 2 tabs po prn menstrual cramps.
• OTC Tylenol 500mg 2 tabs po prn.
Allergies: NKDA, none reported.
PMHx: No medical or surgical history to date. Reports being depressed and
anxious over hercurrent symptoms.
Surgical Hx: Denies prior surgical procedures.
Hospitalizati
ons: None
reported.
Preventative
Health
Immunizatio
ns:
• Influenza 10/2021
• Tuberculin skin test November 2021-negative
• SARS-CoV2 Moderna vaccine x 3 2021-2022
• Tetanus 2019
• Tdap series age 5-6
• Hep B series unk age.
• MMR series age 5-6
• Polio age 6
, • Varicella age 6
Social & Substance Hx: Patient reports she loves her job as a full-time
administrative assistant.She drives 15-20 minutes to work. She jogs 3-4
times a week, wears seatbelts when in the car, and “occasionally” uses
sunscreen. Patient lives at home in separate detached in-law apartment on
her parent’s property and reports feeling safe living there. She is the
youngest of three adopted children. 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.
Fam Hx: Family history is non-contributary, patient adopted.
Mental Hx: Reports occasional sadness and anxiety related to her
menstrual cycle. She deniessuicidal or homicidal ideations. Denies seeing
a therapist.
Violence Hx: Had one verbally abusive relationship at age 18. That person
is no longer in herlife.
Sexual/Reproductive Hx: Heterosexually active. G1P0, 1 abortion 2 years
ago. Menarche at age13; menses every 28-32 days, lasting 4-6 day and using
3 tampons daily. LMP: 3/01/22. She reports some cramping during her
menses for which she takes OTC Pamprin. States she has a satisfying sexual
life. She reports practicing vaginal and oral intercourse. Uses pull out
method. No condoms. Denies recent pregnancy.
ROS:
General: Reports general malaise. Reports having had a recent elevated
temperature relieved byOTC Tylenol. Denies chills, nausea, or vomiting. No
unintentional weight loss or gains.
HEENT: Head: denies headaches, vertigo, or trauma. Eyes: denies vision
loss, blurred vision, or double vision. Ears: denies hearing loss, ringing of the
ears. Nose: denies rhinitis. Throat: reports sore throat and swollen lymph
nodes.
Skin: Denies rash, itching, bruising.
Cardiovascular: Denies chest pain, palpitations, or history of heart disease.
Respiratory: Denies SOB, asthma, or breathing difficulties.
Breasts: Denies pain, nipple discharge or retraction.
Gastrointestinal: Denies nausea, vomiting, bloating, diarrhea, or constipation.
Genitourinary: Reports dysuria; vaginal burning, burning with
urination, and thick yellowdischarge.
