CasestudyWeek3.docx
Case study
Case Study 1
Charlene Baja is a 22-year-old G0 P0 L0 who presents to the clinic today for burning and discharge for 1 week. She states her boyfriend recently found out he was positive for chlamydia. She denies any other partners besides him. Her medical history is remarkable for anxiety and depression. Her surgical history is unremarkable. Her social history includes social alcohol, but she denies tobacco and any recreational drugs. She has no known drug allergies and takes a multivitamin and Srintec daily for oral contraception. Her health history reveals that her mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia. Charlene has one brother with no medical history.
· Height 5’ 5” Weight 148 (BMI 24.6), BP 132/68 P 62
· HEENT: WNL
· Neck: lymph nodes grossly normal
· Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam
· Breast: normal breast exam
· Abd: WNL
· VVBSU: WNL
· Cervix: firm, smooth, yellow watery discharge in the large amount present
· Uterus: RV, mobile, non-tender
· Adnexa: WNL
Prepare a focused SOAP note using the attached template.
· Review the Learning Resources for this week and pay close attention to the media program related to 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. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests.
· APA format and 3 up to date bibliographies for the last five years
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.
Additional resources link
. https://www.youtube.com/watch?v=8dgeOPGx6YI&t=3s
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