NRNP 6552 Week 5 Case Studies; Patient Histories and Present Illnesses

Case #1. Diana. History of Present Illness (HPI): Diana is a 48-year-old Hispanic G4P1031. She presents to your office as a new patient for GYN visit. Her last visit to a gynecologist was 12 years ago after the birth of her daughter. Her periods come at variable intervals, sometimes every three months, other times twice in a month. Flow varies from minimal spotting to heavy bleeding requiring pad changes every hour. She reports dysmenorrhea with her periods that is relieved with ibuprofen. She reports a 30-pound weight gain over the past 10 years. Prior medical history: Gallstones. Prior surgical history: Lap cholecystectomy (2008) Current medications: None. Allergies: None OB- GYN History: Surgical TOP x 3. C-section x 1 at full term for arrest of descent. Menarche age 13, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day, until recently. No history of sexually transmitted infections (STDs). No history of abnormal pap smears. Last pap was 12 years ago, reported normal. HIV negative. LMP: 2 weeks ago – heavy with clots and lasted 10 days. Contraception history: None. Social history: Lives with husband and daughter. Stay at home mom. Denies ETOH or recreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English. Family history: Mother s/p hysterectomy for fibroids, sister with diabetes mellitus. Review of Systems (ROS): Negative except as noted in HPI. Physical Exam (PE) VS: BP: 155/80, P: 99, RR: 18, T: 98.4, Weight: 206 lbs., Height 66 in, BMI 33.2 kg/m2 General: NAD, well-appearing, obesity in female Abd: Soft, NT/ND, no masses/HSM GU: No lesions; normal vaginal mucosa; no CMT; no uterine/adnexal tenderness; uterus 8-week size; no adnexal masses Ext: Good CMS, 1+ edema b/l Case #2. Barbara. History of Present Illness (HPI): Barbara is a 73-year-old Caucasian G2P2002. She is a retired schoolteacher, lives alone. She complains of 2-year history of ten episodes of daytime frequency with small frequent voids, a constant desire to urinate, and nocturia x 3 every night, resulting in poor sleep. More recently, symptoms have worsened and now include a sudden urge to void and occasional urinary incontinence with structured physical activity. She changes pads three times a day and complains of superficial dyspareunia. She denies OAB meds or hormone replacement therapy in the past. She complains of mild constipation and has had three lower urinary tract infections (UTIs) in the last 12 months. Prior medical history: HTN, UTI. Prior surgical history: Appendectomy (1998) Current medications: Cardura 2mg daily, furosemide 20mg daily. Allergies: Penicillin OB- GYN History: Forceps-assisted VD x 2. Menarche age 14, normal throughout life. No history of sexually transmitted infections (STDs). Last pap smear age 67 years, normal. LMP: Approximately 25 years ago. Contraception history: None. Social history: Lives alone. Retired schoolteacher. ETOH: 1-2 glasses red wine nightly. No recreational drug use. Never smoked. Plays bingo 3 times weekly and participates in structured physical activity (pickle ball and Pilates) 3-4 times weekly. Family history: Mother (deceased age 79)- CVA. Father (deceased