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  • Caroline casey ihuman UPDATED

Caroline casey ihuman UPDATED

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Caroline casey ihuman UPDATED Caroline casey ihuman UPDATED Caroline casey ihuman UPDATED Caroline casey ihuman UPDATED Caroline casey ihuman Case Study 25 y/o 5’6” (168 cm) 140.0lb (63.6 kg) Reason for encounter 25 year old who desires contraceptive The primary reason is to discuss contraception. I currently use male condoms but my husband and I would like something more spontaneous but I need reliability as we would like to wait 2-3 years before having another child. Approach cc sx when did your fatigues start does your tiredness improve after a good night’s rest How many tampons or pads do you use daily bimanual exam of the uterus is important inspect eyes History Physical Exam Assessment Test Results Diagnosis Plan Summary Organize Key Findings Your Findings Case Findings Write Problem Statement Key Finding MSAP Relation Contraception UNRELATED Menorrhagia MSAP Select Problem Fatigue Categories Select Differential Diagnosis Rank Differential Key Finding Fatigue x 9 months MSAP RELATED Heavy and prolonged menstrual bleeding RELATED Hx DVT on BCP RELATED Uterus slightly bulky, 9-10 weeks RELATED pregnant size Slight conjunctival pallor RELATED Contraception desired UNKNOWN MSAP Relation Diagnosis Select Tests Feedback The problem list or list of pertinent findings you compiled should be a list that includes everything that is out of the ordinary about this patient, even when it is not a "problem" in the true sense of the word. In this case, the patient presents with a desire for a new form of contraception but also relates two significant post pregnancy changes, fatigue and menorrhagia. Selecting the most-significant-active-problem (MSAP) is a bit challenging in this case as all three issues, contraception, fatigue and menstrual bleeding changes are all of importance. In this situation, it may be best to set aside the contraception and focus on fatigue and menstruation. Of these two issues, the differential of fatigue is broader and thus, some of the etiologies causing fatigue could also be responsible for menorrhagia. Therefore, the fatigue was selected as the MSAP. Next look at the other findings you identified in her history and physical exam. Could the conjunctival pallor and heavy menstrual bleeding be linked? How might they result in fatigue? How might the uterus size relate to the problem of fatigue? How does her uterine size compare to the date of her last menstrual period? Does this provide a clue? Finally, don't forget that one of the main reasons she sought medical assistance was to discuss new forms of contraception. She presents with a history of a DVT while on a third generation BCP as well as being allergic to latex. Finally, she wants something that allows "spontaneity" as well as reliability. EHR Proceed

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  • Uploaded

    05 March 2024

  • Updated

    20 January 2026

  • Category

    Nursing

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    questions & answers

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