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Pick one casea year ago24.07.202418Report issuefiles (2)NRNP6552Week9Casestudytemplate.docxNRNP6552week9cases.pdfNRNP6552Week9Casestudytemplate.docxCase # (1, 2, 3 or 4) and Description of the Case Chosen:·Case 1: Teresa·Case 2: Joanna·Case 3: Monica·Case 4: LauraOutline Subjective data.Identify data provided in your chosen case and any additional data needed.OutlineObjective 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 keySocial Determinants of Heath (SDoH) for your chosen case.Describe collaborative care referrals and patient education needs for your chosen case.Describe rationales and supporting references for each.NRNP6552week9cases.pdfCase #1. Teresa.History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your officetoday at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure toprogress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital onday 2 post-partum without complications. Teresa has had difficulty with breast feeding due todiscomfort in her suture line and terrible pain in her right breast since her discharge from the hospital.She reports occasional chills- she has not measured her temperature at home. Teresa was seen by thelactation consultant while in the hospital but “nothing is working” and her son “cries all the time”. Sheis afraid to feed her son formula as her mother-in-law wants her to “keep trying to breastfeed”. Teresatells you she feels as if she has failed her son- “it was so easy with my first baby, I know my husbandthinks I am a bad mother”.Prior medical history: None. Prior surgical history: Appendectomy (2000)Current medications: Prenatal vitamins, stool softener. Allergies: NoneOB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history ofsexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by anormal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history:Oral contraceptives, condoms.Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH orrecreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.Family history: Unremarkable.Review of Systems (ROS): Negative except as noted in HPI.Physical Exam (PE)VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge orlesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam,you do note an erythematous, swollen, and painful area to the right breast. Her physical exam isotherwise unremarkable.Case #2. Joanna.History of Present Illness (HPI): Joanna is a 28-year-old Caucasian G4P1021. She is single, living with herfather and 2-year-old daughter. She has a part-time job as a server at the local restaurant; she does nothave health insurance. Joanna presents to your office at the community health center today stating sheis pregnant and wants to receive OB care. She tells you that she has not yet been evaluated for thispregnancy as she was afraid to take time off from work and did not have enough money to pay for thevisit.Prior medical history: None. Prior surgical history: NoneCurrent medications: None. Allergies: PenicillinOB- GYN History: NSVD (2021) healthy female 6lb 8oz. Menarche age 10, cycle length- 3 days- irregularcycles since menarche- frequency every 20-30 days- 2-3 tampons per day. No history of sexuallytransmitted infections (STDs). Joanna’s OB history includes two first trimester elective terminations ofpregnancy, and 1 term female infant delivered vaginally at 37 weeks. Denies any complications duringher prior pregnancy however, she notes that her daughter experienced hypoglycemia and respiratorydistress, spending 2 weeks in the Neonatal Intensive Care Unit (NICU).LMP: Approximately 5 months ago. Contraception history: Condoms “sometimes”.Social history: Lives with her retired father and daughter. Restaurant server. Denies EtOH orrecreational drug use. Currently smoking 1 pack of cigarettes/ day (15 pack-year history). She and hermother are still paying for her daughter’s NICU stay. The child’s father is not involved in any way.Family history: Mother (deceased age 55)- Type 2 diabetes.Review of Systems (ROS): Unremarkable with exception of dysuria (“it burns when I pee”) over the past1-week. Denies fever, chills, abdominal or flank pain. Thick white vaginal discharge and “itching” for thepast month.Physical Exam (PE)VS: BP: 108/68, P: 72, RR: 18, T: 37.3, Weight 144lbsOn physical exam you palpate a fundal height of approximately 20cm with an audible fetal heart tone(FHT) of 160. On speculum exam you visualize a multiparous cervix without lesions; bluish discolorationof the cervix, vagina, and vulva is noted with a thick, white discharge. There is no cervical motiontenderness (CMT) on exam. The uterus is anteverted, non- tender, with fundus palpable at theumbilicus. Joanna’s physical exam is otherwise unremarkable.Wet mount reveals budding yeast. Urine dipstick with 1+ leukocytes, trace blood and 2+ glucose.Case #3. Monica.History of Present Illness (HPI): Monica is a 43-year-old African- American G3P2102. She is currentlyseparated from her husband of 20 years and is working full-time as a legal secretary. About 8 monthsago, Monica started having irregular periods with heavier than usual flow until she stopped havingperiods or any vaginal bleeding about 3 months ago. She is currently recovering from a “stomach flu”however, she reports daily nausea, vomiting, bloating and decreased appetite over the past 3 weeks.She is worried because she has gained 12 pounds over the last 3 months “due to menopause”. Shecomes to the clinic today to discuss menopause symptoms and hormone replacement therapy.Prior medical history: Hypertension (2010)- well controlled on current antihypertensivePrior surgical history: Cholecystectomy (2015)Current medications: Lisinopril 10mg daily. Allergies: NoneOB- GYN History: NSVD x 2 (2015, 2019) healthy female 6lb 8oz; healthy female 7lbs 6oz. First trimestermiscarriage (9 weeks) in 2014. Menarche age 15, cycle length-7 days- frequency every 28 days- 5-6 padsper day. No history of sexually transmitted infections (STDs). No history of abnormal pap (last pap 2years ago).LMP: Approximately 3 months ago. Contraception history: Condoms; past use of oral contraceptives.Social history: Lives with her elderly father, 2 daughters. Separated from her husband for 6 months.Family history: Mother deceased (age 60)- breast cancer. Father alive (age 70)- hypertension.Review of Systems (ROS): Unremarkable with exception of as noted in HPI.Physical Exam (PE)VS: BP: 130/78, P: 78, RR: 18, T: 36.1 Weight: 152 lbs.Physical exam is unremarkable with exception of a palpable 12- 14 weeks size uterus on bimanual. Youcheck a for a fetal heartbeat and obtain a heart tone of 145 via doppler. The intake nurse reports that aurine pregnancy test came back positive.Monica is in disbelief.Case #4. Laura.History of Present Illness (HPI): Laura is a 16-year-old Caucasian G1P0. She presents to your office aftermissing her second period. She is “worried” as she “always gets her period on time”. She is in highschool- about to enter the 11th grade. She lives with her grandmother and 2 older siblings. Her urinepregnancy test in clinic today is positive.Laura is sexually active with her boyfriend; they do not use condoms. He “pulls out” as birth control.She reports being treated at the health department for chlamydia and gonorrhea earlier this year. Shethinks her boyfriend was treated but he is not answering her calls since she told him about the missedperiods a few weeks ago. She reports daily nausea, vomiting and dysuria for the past 2 weeks.Prior medical history: None. Prior surgical history: NoneCurrent medications: None. Allergies: NoneOB- GYN History: Menarche age 12, cycle length-7 days- frequency every 30 days- 2 tampons per day.History of chlamydia and gonorrhea (GC) in the past year. Last pap reported normal at the time ofchlamydia/ GC diagnosis. Has not received Human Papillomavirus (HPV) vaccine.LMP: Approximately 2 months ago. Contraception history: WithdrawalSocial history: Lives with her grandmother, siblings. Denies EtOH or recreational drug use. Currentlysmoking 1 pack of cigarettes/ dayFamily history: Mother deceased at age 42- drug overdose. Father unknown.Review of Systems (ROS): Unremarkable with exception of as noted in HPI.Physical Exam (PE)VS: BP: 110/68, P: 80, RR: 18, T: 37.1 Weight: 110 lbs. (states usual weight 120 lbs.).Physical exam is unremarkable with exception of a cloudy, yellow mucoid cervical discharge on speculumexam; friable appearance of the cervix with cervical motion tenderness (CMT). You palpate an 8-weeksize uterus on bimanual.Laura’s urine reveals 2+ ketones, 2+ nitrates, and 3+ leukocytes.NRNP6552week9cases.pdfCase #1. Teresa.History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your officetoday at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure toprogress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital onday 2 post-partum without complications. Teresa has had difficulty with breast feeding due todiscomfort in her suture line and terrible pain in her right breast since her discharge from the hospital.She reports occasional chills- she has not measured her temperature at home. Teresa was seen by thelactation consultant while in the hospital but “nothing is working” and her son “cries all the time”. Sheis afraid to feed her son formula as her mother-in-law wants her to “keep trying to breastfeed”. Teresatells you she feels as if she has failed her son- “it was so easy with my first baby, I know my husbandthinks I am a bad mother”.Prior medical history: None. Prior surgical history: Appendectomy (2000)Current medications: Prenatal vitamins, stool softener. Allergies: NoneOB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history ofsexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by anormal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history:Oral contraceptives, condoms.Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH orrecreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.Family history: Unremarkable.Review of Systems (ROS): Negative except as noted in HPI.Physical Exam (PE)VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge orlesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam,you do note an erythematous, swollen, and painful area to the right breast. Her physical exam isotherwise unremarkable.Case #2. Joanna.History of Present Illness (HPI): Joanna is a 28-year-old Caucasian G4P1021. She is single, living with herfather and 2-year-old daughter. She has a part-time job as a server at the local restaurant; she does nothave health insurance. Joanna presents to your office at the community health center today stating sheis pregnant and wants to receive OB care. She tells you that she has not yet been evaluated for thispregnancy as she was afraid to take time off from work and did not have enough money to pay for thevisit.Prior medical history: None. Prior surgical history: NoneCurrent medications: None. Allergies: PenicillinOB- GYN History: NSVD (2021) healthy female 6lb 8oz. Menarche age 10, cycle length- 3 days- irregularcycles since menarche- frequency every 20-30 days- 2-3 tampons per day. No history of sexuallytransmitted infections (STDs). Joanna’s OB history includes two first trimester elective terminations ofpregnancy, and 1 term female infant delivered vaginally at 37 weeks. Denies any complications duringher prior pregnancy however, she notes that her daughter experienced hypoglycemia and respiratorydistress, spending 2 weeks in the Neonatal Intensive Care Unit (NICU).LMP: Approximately 5 months ago. Contraception history: Condoms “sometimes”.Social history: Lives with her retired father and daughter. Restaurant server. Denies EtOH orrecreational drug use. Currently smoking 1 pack of cigarettes/ day (15 pack-year history). She and hermother are still paying for her daughter’s NICU stay. The child’s father is not involved in any way.Family history: Mother (deceased age 55)- Type 2 diabetes.Review of Systems (ROS): Unremarkable with exception of dysuria (“it burns when I pee”) over the past1-week. Denies fever, chills, abdominal or flank pain. Thick white vaginal discharge and “itching” for thepast month.Physical Exam (PE)VS: BP: 108/68, P: 72, RR: 18, T: 37.3, Weight 144lbsOn physical exam you palpate a fundal height of approximately 20cm with an audible fetal heart tone(FHT) of 160. On speculum exam you visualize a multiparous cervix without lesions; bluish discolorationof the cervix, vagina, and vulva is noted with a thick, white discharge. There is no cervical motiontenderness (CMT) on exam. The uterus is anteverted, non- tender, with fundus palpable at theumbilicus. Joanna’s physical exam is otherwise unremarkable.Wet mount reveals budding yeast. Urine dipstick with 1+ leukocytes, trace blood and 2+ glucose.Case #3. Monica.History of Present Illness (HPI): Monica is a 43-year-old African- American G3P2102. She is currentlyseparated from her husband of 20 years and is working full-time as a legal secretary. About 8 monthsago, Monica started having irregular periods with heavier than usual flow until she stopped havingperiods or any vaginal bleeding about 3 months ago. She is currently recovering from a “stomach flu”however, she reports daily nausea, vomiting, bloating and decreased appetite over the past 3 weeks.She is worried because she has gained 12 pounds over the last 3 months “due to menopause”. Shecomes to the clinic today to discuss menopause symptoms and hormone replacement therapy.Prior medical history: Hypertension (2010)- well controlled on current antihypertensivePrior surgical history: Cholecystectomy (2015)Current medications: Lisinopril 10mg daily. Allergies: NoneOB- GYN History: NSVD x 2 (2015, 2019) healthy female 6lb 8oz; healthy female 7lbs 6oz. First trimestermiscarriage (9 weeks) in 2014. Menarche age 15, cycle length-7 days- frequency every 28 days- 5-6 padsper day. No history of sexually transmitted infections (STDs). No history of abnormal pap (last pap 2years ago).LMP: Approximately 3 months ago. Contraception history: Condoms; past use of oral contraceptives.Social history: Lives with her elderly father, 2 daughters. Separated from her husband for 6 months.Family history: Mother deceased (age 60)- breast cancer. Father alive (age 70)- hypertension.Review of Systems (ROS): Unremarkable with exception of as noted in HPI.Physical Exam (PE)VS: BP: 130/78, P: 78, RR: 18, T: 36.1 Weight: 152 lbs.Physical exam is unremarkable with exception of a palpable 12- 14 weeks size uterus on bimanual. Youcheck a for a fetal heartbeat and obtain a heart tone of 145 via doppler. The intake nurse reports that aurine pregnancy test came back positive.Monica is in disbelief.Case #4. Laura.History of Present Illness (HPI): Laura is a 16-year-old Caucasian G1P0. She presents to your office aftermissing her second period. She is “worried” as she “always gets her period on time”. She is in highschool- about to enter the 11th grade. She lives with her grandmother and 2 older siblings. Her urinepregnancy test in clinic today is positive.Laura is sexually active with her boyfriend; they do not use condoms. He “pulls out” as birth control.She reports being treated at the health department for chlamydia and gonorrhea earlier this year. Shethinks her boyfriend was treated but he is not answering her calls since she told him about the missedperiods a few weeks ago. She reports daily nausea, vomiting and dysuria for the past 2 weeks.Prior medical history: None. Prior surgical history: NoneCurrent medications: None. Allergies: NoneOB- GYN History: Menarche age 12, cycle length-7 days- frequency every 30 days- 2 tampons per day.History of chlamydia and gonorrhea (GC) in the past year. Last pap reported normal at the time ofchlamydia/ GC diagnosis. Has not received Human Papillomavirus (HPV) vaccine.LMP: Approximately 2 months ago. Contraception history: WithdrawalSocial history: Lives with her grandmother, siblings. Denies EtOH or recreational drug use. Currentlysmoking 1 pack of cigarettes/ dayFamily history: Mother deceased at age 42- drug overdose. Father unknown.Review of Systems (ROS): Unremarkable with exception of as noted in HPI.Physical Exam (PE)VS: BP: 110/68, P: 80, RR: 18, T: 37.1 Weight: 110 lbs. (states usual weight 120 lbs.).Physical exam is unremarkable with exception of a cloudy, yellow mucoid cervical discharge on speculumexam; friable appearance of the cervix with cervical motion tenderness (CMT). You palpate an 8-weeksize uterus on bimanual.Laura’s urine reveals 2+ ketones, 2+ nitrates, and 3+ leukocytes.NRNP6552Week9Casestudytemplate.docxCase # (1, 2, 3 or 4) and Description of the Case Chosen:·Case 1: Teresa·Case 2: Joanna·Case 3: Monica·Case 4: LauraOutline Subjective data.Identify data provided in your chosen case and any additional data needed.OutlineObjective 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 keySocial Determinants of Heath (SDoH) for your chosen case.Describe collaborative care referrals and patient education needs for your chosen case.Describe rationales and supporting references for each.NRNP6552week9cases.pdfCase #1. Teresa.History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your officetoday at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure toprogress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital onday 2 post-partum without complications. Teresa has had difficulty with breast feeding due todiscomfort in her suture line and terrible pain in her right breast since her discharge from the hospital.She reports occasional chills- she has not measured her temperature at home. Teresa was seen by thelactation consultant while in the hospital but “nothing is working” and her son “cries all the time”. Sheis afraid to feed her son formula as her mother-in-law wants her to “keep trying to breastfeed”. Teresatells you she feels as if she has failed her son- “it was so easy with my first baby, I know my husbandthinks I am a bad mother”.Prior medical history: None. Prior surgical history: Appendectomy (2000)Current medications: Prenatal vitamins, stool softener. Allergies: NoneOB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history ofsexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by anormal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history:Oral contraceptives, condoms.Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH orrecreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.Family history: Unremarkable.Review of Systems (ROS): Negative except as noted in HPI.Physical Exam (PE)VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge orlesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam,you do note an erythematous, swollen, and painful area to the right breast. Her physical exam isotherwise unremarkable.Case #2. Joanna.History of Present Illness (HPI): Joanna is a 28-year-old Caucasian G4P1021. She is single, living with herfather and 2-year-old daughter. She has a part-time job as a server at the local restaurant; she does nothave health insurance. Joanna presents to your office at the community health center today stating sheis pregnant and wants to receive OB care. She tells you that she has not yet been evaluated for thispregnancy as she was afraid to take time off from work and did not have enough money to pay for thevisit.Prior medical history: None. Prior surgical history: NoneCurrent medications: None. Allergies: PenicillinOB- GYN History: NSVD (2021) healthy female 6lb 8oz. Menarche age 10, cycle length- 3 days- irregularcycles since menarche- frequency every 20-30 days- 2-3 tampons per day. No history of sexuallytransmitted infections (STDs). Joanna’s OB history includes two first trimester elective terminations ofpregnancy, and 1 term female infant delivered vaginally at 37 weeks. Denies any complications duringher prior pregnancy however, she notes that her daughter experienced hypoglycemia and respiratorydistress, spending 2 weeks in the Neonatal Intensive Care Unit (NICU).LMP: Approximately 5 months ago. Contraception history: Condoms “sometimes”.Social history: Lives with her retired father and daughter. Restaurant server. Denies EtOH orrecreational drug use. Currently smoking 1 pack of cigarettes/ day (15 pack-year history). She and hermother are still paying for her daughter’s NICU stay. The child’s father is not involved in any way.Family history: Mother (deceased age 55)- Type 2 diabetes.Review of Systems (ROS): Unremarkable with exception of dysuria (“it burns when I pee”) over the past1-week. Denies fever, chills, abdominal or flank pain. Thick white vaginal discharge and “itching” for thepast month.Physical Exam (PE)VS: BP: 108/68, P: 72, RR: 18, T: 37.3, Weight 144lbsOn physical exam you palpate a fundal height of approximately 20cm with an audible fetal heart tone(FHT) of 160. On speculum exam you visualize a multiparous cervix without lesions; bluish discolorationof the cervix, vagina, and vulva is noted with a thick, white discharge. There is no cervical motiontenderness (CMT) on exam. The uterus is anteverted, non- tender, with fundus palpable at theumbilicus. Joanna’s physical exam is otherwise unremarkable.Wet mount reveals budding yeast. Urine dipstick with 1+ leukocytes, trace blood and 2+ glucose.Case #3. Monica.History of Present Illness (HPI): Monica is a 43-year-old African- American G3P2102. She is currentlyseparated from her husband of 20 years and is working full-time as a legal secretary. About 8 monthsago, Monica started having irregular periods with heavier than usual flow until she stopped havingperiods or any vaginal bleeding about 3 months ago. She is currently recovering from a “stomach flu”however, she reports daily nausea, vomiting, bloating and decreased appetite over the past 3 weeks.She is worried because she has gained 12 pounds over the last 3 months “due to menopause”. Shecomes to the clinic today to discuss menopause symptoms and hormone replacement therapy.Prior medical history: Hypertension (2010)- well controlled on current antihypertensivePrior surgical history: Cholecystectomy (2015)Current medications: Lisinopril 10mg daily. Allergies: NoneOB- GYN History: NSVD x 2 (2015, 2019) healthy female 6lb 8oz; healthy female 7lbs 6oz. First trimestermiscarriage (9 weeks) in 2014. Menarche age 15, cycle length-7 days- frequency every 28 days- 5-6 padsper day. No history of sexually transmitted infections (STDs). No history of abnormal pap (last pap 2years ago).LMP: Approximately 3 months ago. Contraception history: Condoms; past use of oral contraceptives.Social history: Lives with her elderly father, 2 daughters. Separated from her husband for 6 months.Family history: Mother deceased (age 60)- breast cancer. Father alive (age 70)- hypertension.Review of Systems (ROS): Unremarkable with exception of as noted in HPI.Physical Exam (PE)VS: BP: 130/78, P: 78, RR: 18, T: 36.1 Weight: 152 lbs.Physical exam is unremarkable with exception of a palpable 12- 14 weeks size uterus on bimanual. Youcheck a for a fetal heartbeat and obtain a heart tone of 145 via doppler. The intake nurse reports that aurine pregnancy test came back positive.Monica is in disbelief.Case #4. Laura.History of Present Illness (HPI): Laura is a 16-year-old Caucasian G1P0. She presents to your office aftermissing her second period. She is “worried” as she “always gets her period on time”. She is in highschool- about to enter the 11th grade. She lives with her grandmother and 2 older siblings. Her urinepregnancy test in clinic today is positive.Laura is sexually active with her boyfriend; they do not use condoms. He “pulls out” as birth control.She reports being treated at the health department for chlamydia and gonorrhea earlier this year. Shethinks her boyfriend was treated but he is not answering her calls since she told him about the missedperiods a few weeks ago. She reports daily nausea, vomiting and dysuria for the past 2 weeks.Prior medical history: None. Prior surgical history: NoneCurrent medications: None. Allergies: NoneOB- GYN History: Menarche age 12, cycle length-7 days- frequency every 30 days- 2 tampons per day.History of chlamydia and gonorrhea (GC) in the past year. Last pap reported normal at the time ofchlamydia/ GC diagnosis. Has not received Human Papillomavirus (HPV) vaccine.LMP: Approximately 2 months ago. Contraception history: WithdrawalSocial history: Lives with her grandmother, siblings. Denies EtOH or recreational drug use. Currentlysmoking 1 pack of cigarettes/ dayFamily history: Mother deceased at age 42- drug overdose. Father unknown.Review of Systems (ROS): Unremarkable with exception of as noted in HPI.Physical Exam (PE)VS: BP: 110/68, P: 80, RR: 18, T: 37.1 Weight: 110 lbs. (states usual weight 120 lbs.).Physical exam is unremarkable with exception of a cloudy, yellow mucoid cervical discharge on speculumexam; friable appearance of the cervix with cervical motion tenderness (CMT). You palpate an 8-weeksize uterus on bimanual.Laura’s urine reveals 2+ ketones, 2+ nitrates, and 3+ leukocytes.NRNP6552Week9Casestudytemplate.docxCase # (1, 2, 3 or 4) and Description of the Case Chosen:·Case 1: Teresa·Case 2: Joanna·Case 3: Monica·Case 4: LauraOutline Subjective data.Identify data provided in your chosen case and any additional data needed.OutlineObjective 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 keySocial Determinants of Heath (SDoH) for your chosen case.Describe collaborative care referrals and patient education needs for your chosen case.Describe rationales and supporting references for each.NRNP6552week9cases.pdfCase #1. Teresa.History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your officetoday at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure toprogress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital onday 2 post-partum without complications. Teresa has had difficulty with breast feeding due todiscomfort in her suture line and terrible pain in her right breast since her discharge from the hospital.She reports occasional chills- she has not measured her temperature at home. Teresa was seen by thelactation consultant while in the hospital but “nothing is working” and her son “cries all the time”. Sheis afraid to feed her son formula as her mother-in-law wants her to “keep trying to breastfeed”. Teresatells you she feels as if she has failed her son- “it was so easy with my first baby, I know my husbandthinks I am a bad mother”.Prior medical history: None. Prior surgical history: Appendectomy (2000)Current medications: Prenatal vitamins, stool softener. Allergies: NoneOB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history ofsexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by anormal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history:Oral contraceptives, condoms.Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH orrecreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.Family history: Unremarkable.Review of Systems (ROS): Negative except as noted in HPI.Physical Exam (PE)VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge orlesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam,you do note an erythematous, swollen, and painful area to the right breast. Her physical exam isotherwise unremarkable.Case #2. Joanna.History of Present Illness (HPI): Joanna is a 28-year-old Caucasian G4P1021. She is single, living with herfather and 2-year-old daughter. She has a part-time job as a server at the local restaurant; she does nothave health insurance. Joanna presents to your office at the community health center today stating sheis pregnant and wants to receive OB care. She tells you that she has not yet been evaluated for thispregnancy as she was afraid to take time off from work and did not have enough money to pay for thevisit.Prior medical history: None. Prior surgical history: NoneCurrent medications: None. Allergies: PenicillinOB- GYN History: NSVD (2021) healthy female 6lb 8oz. Menarche age 10, cycle length- 3 days- irregularcycles since menarche- frequency every 20-30 days- 2-3 tampons per day. No history of sexuallytransmitted infections (STDs). Joanna’s OB history includes two first trimester elective terminations ofpregnancy, and 1 term female infant delivered vaginally at 37 weeks. Denies any complications duringher prior pregnancy however, she notes that her daughter experienced hypoglycemia and respiratorydistress, spending 2 weeks in the Neonatal Intensive Care Unit (NICU).LMP: Approximately 5 months ago. Contraception history: Condoms “sometimes”.Social history: Lives with her retired father and daughter. Restaurant server. Denies EtOH orrecreational drug use. Currently smoking 1 pack of cigarettes/ day (15 pack-year history). She and hermother are still paying for her daughter’s NICU stay. The child’s father is not involved in any way.Family history: Mother (deceased age 55)- Type 2 diabetes.Review of Systems (ROS): Unremarkable with exception of dysuria (“it burns when I pee”) over the past1-week. Denies fever, chills, abdominal or flank pain. Thick white vaginal discharge and “itching” for thepast month.Physical Exam (PE)VS: BP: 108/68, P: 72, RR: 18, T: 37.3, Weight 144lbsOn physical exam you palpate a fundal height of approximately 20cm with an audible fetal heart tone(FHT) of 160. On speculum exam you visualize a multiparous cervix without lesions; bluish discolorationof the cervix, vagina, and vulva is noted with a thick, white discharge. There is no cervical motiontenderness (CMT) on exam. The uterus is anteverted, non- tender, with fundus palpable at theumbilicus. Joanna’s physical exam is otherwise unremarkable.Wet mount reveals budding yeast. Urine dipstick with 1+ leukocytes, trace blood and 2+ glucose.Case #3. Monica.History of Present Illness (HPI): Monica is a 43-year-old African- American G3P2102. She is currentlyseparated from her husband of 20 years and is working full-time as a legal secretary. About 8 monthsago, Monica started having irregular periods with heavier than usual flow until she stopped havingperiods or any vaginal bleeding about 3 months ago. She is currently recovering from a “stomach flu”however, she reports daily nausea, vomiting, bloating and decreased appetite over the past 3 weeks.She is worried because she has gained 12 pounds over the last 3 months “due to menopause”. Shecomes to the clinic today to discuss menopause symptoms and hormone replacement therapy.Prior medical history: Hypertension (2010)- well controlled on current antihypertensivePrior surgical history: Cholecystectomy (2015)Current medications: Lisinopril 10mg daily. Allergies: NoneOB- GYN History: NSVD x 2 (2015, 2019) healthy female 6lb 8oz; healthy female 7lbs 6oz. First trimestermiscarriage (9 weeks) in 2014. Menarche age 15, cycle length-7 days- frequency every 28 days- 5-6 padsper day. No history of sexually transmitted infections (STDs). No history of abnormal pap (last pap 2years ago).LMP: Approximately 3 months ago. Contraception history: Condoms; past use of oral contraceptives.Social history: Lives with her elderly father, 2 daughters. Separated from her husband for 6 months.Family history: Mother deceased (age 60)- breast cancer. Father alive (age 70)- hypertension.Review of Systems (ROS): Unremarkable with exception of as noted in HPI.Physical Exam (PE)VS: BP: 130/78, P: 78, RR: 18, T: 36.1 Weight: 152 lbs.Physical exam is unremarkable with exception of a palpable 12- 14 weeks size uterus on bimanual. Youcheck a for a fetal heartbeat and obtain a heart tone of 145 via doppler. The intake nurse reports that aurine pregnancy test came back positive.Monica is in disbelief.Case #4. Laura.History of Present Illness (HPI): Laura is a 16-year-old Caucasian G1P0. She presents to your office aftermissing her second period. She is “worried” as she “always gets her period on time”. She is in highschool- about to enter the 11th grade. She lives with her grandmother and 2 older siblings. Her urinepregnancy test in clinic today is positive.Laura is sexually active with her boyfriend; they do not use condoms. He “pulls out” as birth control.She reports being treated at the health department for chlamydia and gonorrhea earlier this year. Shethinks her boyfriend was treated but he is not answering her calls since she told him about the missedperiods a few weeks ago. She reports daily nausea, vomiting and dysuria for the past 2 weeks.Prior medical history: None. Prior surgical history: NoneCurrent medications: None. Allergies: NoneOB- GYN History: Menarche age 12, cycle length-7 days- frequency every 30 days- 2 tampons per day.History of chlamydia and gonorrhea (GC) in the past year. Last pap reported normal at the time ofchlamydia/ GC diagnosis. Has not received Human Papillomavirus (HPV) vaccine.LMP: Approximately 2 months ago. Contraception history: WithdrawalSocial history: Lives with her grandmother, siblings. Denies EtOH or recreational drug use. Currentlysmoking 1 pack of cigarettes/ dayFamily history: Mother deceased at age 42- drug overdose. Father unknown.Review of Systems (ROS): Unremarkable with exception of as noted in HPI.Physical Exam (PE)VS: BP: 110/68, P: 80, RR: 18, T: 37.1 Weight: 110 lbs. (states usual weight 120 lbs.).Physical exam is unremarkable with exception of a cloudy, yellow mucoid cervical discharge on speculumexam; friable appearance of the cervix with cervical motion tenderness (CMT). You palpate an 8-weeksize uterus on bimanual.Laura’s urine reveals 2+ ketones, 2+ nitrates, and 3+ leukocytes.12Bids(56)Miss DeannaDr. Ellen RMMISS HILLARY A+Sheryl HoganProf. TOPGRADEEmily ClareDr. Sarah Blakefirstclass tutorDoctor.NamiraDr. Freya WalkerPROF_ALISTERMUSYOKIONES A+Dr CloverDiscount AssigngrA+de plusProWritingGuruDr. Everleigh_JKColeen AndersonIsabella HarvardBrilliant GeekShow All Bidsother Questions(10)Hmong HistoryAfrican American philosophy paper6Week 6 Discussion: HRM 500improving thisAPPLEassignmentOrganizational Behavior Week 5 DiscussionIdentify a company in your local or generalized area that you would classify as a monopoly. Explain the key reasons why you classified the company as a monopoly, and state how the company operates relative to at least two (2) characteristics of that partiThyrmodynamicsInternational BUSNESS

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