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
• HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears 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.
QUESTIONS:
- What other information do you need?
- What testing would you perform/order?
- What are your initial thoughts for diagnosis?
By Day 3
1) Based on the case study scenario provided, complete a comprehensive well-woman exam and critically analyze the exam to focus attention on the diagnostic tests. Then,
2) Post your primary diagnosis. Include the additional questions you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask for. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)
3) Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations.
Sample Solution
