Women’s Health Assignment

• Provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
• Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.
• Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.

• Use the Focused SOAP Note Template found in the Learning Resources to support Discussion. It is to be set up like a soap note. ( will attach)

Case Study: Dysfunctional Uterine Bleeding
Gretchen Abernathy is a 38-year-old G2 P2 Caucasian female who presents to the clinic with complaints of frequent menstrual bleeding. Her menstrual calendar shows bleeding frequency 17-36 days, lasting 5-10 days in duration and on her heaviest day she needs to change her super tampon every 2 hours. She relates this has been getting worse since stopping her OCP’s when she had a bilateral tubal ligation 4 months after having her second child 9 months ago. She is upset as no one told her that weight gain could happen after and relates she has gained 27 lbs. since her surgery. She states that all this bleeding is making her tired and she cannot keep herself awake. Gretchen’s mother told her she probably just had “low iron” and if she took vitamins, she would feel better.
• HEENT: wnl, hair dry, neck supple without adenopathy
• CV: RSR without murmur or gallop
• Lungs: clear to p&a.
• Abd soft, non-tender, BS all 4 quadrant.
• VVBSU: WNL
• Cervix: firm, smooth, parous, w/o CMT
• Uterus: mid mobile non tender, approximately 10 cm
• Adnexa: without masses or tenderness
• Extremities: negative homan’s, reflexes 2+ = bilaterally, no edema

SAMPLE SOLUTION

Episodic/Focus Note Template

Patient Information:
G.A. is a 38 y/o, G2 P2 Caucasian, Female
S.
CC Chief concern of “frequent menstrual bleeding” with the menstrual calendar showing a bleeding frequency 17-36 days that last for 5-10 days
HPI: G.A. is a 38 y/o, G2 P2 Caucasian, Female who comes to the clinical care setting complaining of elevated menstrual bleeding. The calendar shows that on her heaviest day, she experiences a lot of flow which requires her to change her super tampon after every 5-10 days

Location: Frequent menstrual and vaginal bleeding
Onset: 17-36 days, lasting 5-10 days during the heaviest day.
Character: The flow is described as “heavy and frequent”.
Associated signs and symptoms: Weight gain, feeling fatigued and cannot sleep
Timing: The situation has been getting worse since stopping her OCP’s when she had a bilateral tubal ligation 4 months after having her second child 9 months ago…