Case examine 1
Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your clinic today to sift-canvass contraceptive options. She states that she is not spirited in having over children but her new spouse has never fathered a child. Her medical truth is distinguished for exercise-induced asthma, migraines, and IBS. Her surgical truth is distinguished barely for tonsils as a child. Her political truth is privative for alcohol, tobacco, and recreational offals. She has no known offal allergies and takes barely vitamin C. Hospitalizations were barely for childbirth. Family truth reveals that her kind grandmother is existing delay dementia, timeliness her kind grandfather is existing delay COPD. Her hereditary grandparents are twain deceased due to an automovable garb. Her mother is existing delay osteopenia and fibromyalgia, and her dad is existing delay a truth of peel cancer (basal cell). Elaine has one older sister delay no medical problems and one younger match delay no reputed medical problems.
· Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 Pulse 68
· HEENT (head, ears, eyes, nose, throat): wnl (amid natural expression)
· Neck: yielding delayout adenopathy
· Lungs/CV (cardiovascular): wnl
· Breast: gentle, fibrocystic changes bilaterally, extraneously masses, dimpling or discharge
· Abd (abdomen): gentle, +BS (absolute bowel probe), no sensibility
· VVBSU (Vulvar vaginal bartholin skene’s uretha): wnl, except 1st degree cystocele
· Cervix: solid, level, parous, delayout CMT (cervical noise sensibility)
· Uterus: RV (retroverted), movable, non-tender, approximately 10 cm,
· Adnexa: delayout masses or sensibility
Based on the occurrence examine scenario supposing, consummate a pregnant well-woman exam and critically excite to centre consideration on the symptom tests (comprise exposition of the tests you jurisdiction commend).
Include your differential personality. Be specific and cater examples. Use your Learning Resources and/or proof from learning to buttress your expositions.
Some questions to exculpation in your post:
1. What other instruction do you deficiency?
2. What has she used in the past? Why did she plug a method? How manifold spouses in departed 12 months?
3. What are her popular cycles love?
4. When was her decisive gyn exam and what were the results of the tests?
5. Are her migraines delay or delayout auras?
6. What rule has she considered.
7. What are you next steps/considerations?
8. What instruction should you do?
9. What rules are expend for Elaine?
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