NURS 6552 | Case Study Analysis of Nadine: A Young Female Seeking Birth Control | Answered Correctly.

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History of Present Illness (HPI): Nadine is a 22-year-old female G0 who presents for a well woman exam. She is interested in starting birth control. She is sexually active with her boyfriend; they d... o not use condoms. Prior medical history: Sickle cell trait, Systemic lupus erythematosus (SLE), Pulmonary embolism, Dysmenorrhea. Prior surgical history: None Current medications: Plaquenil, Cellcept, prednisone, lisinopril, Eliquis, atorvastatin, omeprazole. Allergies: None OB- GYN History: Menarche age 12, cycle length-5 days- frequency every 28 days- 3 tampons per day. History of chlamydia in the past year. Has received Human Papillomavirus (HPV) vaccine series. LMP: 3 weeks ago. Contraception history: Withdrawal Social history: Lives with her sister. Denies EtOH or recreational drug use. Vapes daily. Does not exercise. Poor diet – fast food and sodas. Family history: Mother alive – sickle cell. Father alive - HTN. Review of Systems (ROS): Unremarkable. Physical Exam (PE) VS: BP: 133/68, P: 87, RR: 18, T: 98.2 Weight: 188 lbs., Height 64”, BMI 32.3 Lab – urine pregnancy test negative General: Obesity in female. Oriented x 3. Pleasant. Integumentary: Warm, dry, and intact. Abdomen: Soft, NTND, BS present x 4. External: Appropriate hair distribution, No lesions or erythema. Speculum exam: No discharge, no lesions, no cervical motion tenderness (CMT). Bimanual exam: uterus normal size firm and non-tender. No adnexal masses palpated bilaterally, nontender. Breast exam normal. Outline Subjective data. Identify data provided in this case and any additional data needed. Outline Objective findings. Identify findings provided in your chosen case and any additional data needed Identify diagnostic tests, procedures, laboratory work indicated. Describe the rationale for each test or intervention with supporting references. Distinguish at least three differential diagnoses. Describe the rationales for your choice of each diagnosis with supporting references. Identify appropriate medications, treatments or other interventions associated with each differential diagnosis. Describe rationales and supporting references for each. Explain key Social Determinants of Heath (SDoH) for this case Describe collaborative care referrals and patient education needs for this case Describe rationales and supporting references for each. Case Study Analysis of Nadine: A Young Female Seeking Birth Control Subjective Data Nadine, a 22-year-old female with a significant medical history, presents for a well-woman examination and expresses her interest in starting birth control. She is sexually active, using withdrawal as contraception, and reports that her menstrual cycles are regular, occurring every 28 days. Notably, she has a history of chlamydia within the past year and does not use condoms, which raises concerns regarding sexually transmitted infections (STIs). Her medical history includes systemic lupus erythematosus (SLE), a history of pulmonary embolism, and sickle cell trait, making her a candidate for a comprehensive evaluation of contraceptive options that consider both her current medications and existing health conditions. Nadine lives with her sister, does not consume alcohol or recreational drugs but vapes daily and has dietary habits that may contribute to her obesity, underlining an important aspect of her overall health management. [Show More]

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