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Setting: You are an FNP (primary care provider) in a primary care office.
You ar
Setting: You are an FNP (primary care provider) in a primary care office.
You are responsible for all medical care of the patient that presents in this case
study.
Be sure to not only focus on the chief complaint, but the overall care of the presenting
patient.
D.S. is a 45 y.o. A.A. woman presents with complaints of five days of “discomfort” while
urinating, vaginal discomfort, vaginal itching, labial swelling/irritation and thick, white-
yellow vaginal discharge. She denies fever, abdominal pain, or flank pain. Symptoms
started two days after recent sexual activity with new male partner without condom
about one week ago, first partner since divorce two years ago. She uses OCP Junel Fe
1/20 for birth control, reports she remembers “most of the time”. She reports “I’m sad
and tired all the time” since the loss of her mother nine months ago. She has “annoying
headaches” that have caused her to miss work since mother’s death. She was last seen
in clinic >2 years ago. She reports “I’ve just had too much going on.”
PMH: morbid obesity, iron deficiency anemia
PSH: LGBP at age 28, cholecystectomy at age 30
OB History: G2P2, both vaginal deliveries
Family History: Mother with triple negative breast cancer at age 40, ovarian cancer at
age 55, deceased. Father with HTN and DMII, alive. Paternal grandfather with DMII,
HTN, and CKD, deceased.
Social History: Divorced from husband, only lifetime sexual partner. Has two living
children, ages 10 and 8, father has been out of the picture since moving out of state two
years ago. She is primary caregiver for her children/parents, works full time in medical
office as an administrator. Reports rare alcohol use, denies smoking or illicit drug use.
No formal exercise and nutrition “could be a lot better, we eat out a lot”.
Allergies: Environmental, NSAIDs avoided due to hx of LGBP.
Meds: Ferrous sulfate BID when she remembers, Vitamin B12 daily when she
remembers, Junel Fe 1/20 daily, Acetaminophen 1000 mg BID PRN.
Health Care Maintenance:
• Immunizations: Td 9/2018; Flu 10/2022
• PAP: 4 years ago, ASCUS with negative HPV, never followed up
VS:
BP: 152/100; HR 86; Ht: 5’4; Wt: 265#
Labs:
• Wet Prep Today: WBCs (8 WBC/HPF), Pseudohyphae and yeast buds present,
pH 4.3
• Urinalysis: Negative nitrates, +70 leukocytes, negative blood, negative glucose,
negative protein
Exam:
• Abdominal Exam: Unremarkable
• GU: External genitalia with erythema, swelling, excoriation of labia and perineum.
Vaginal mucosa also erythema, no lesions noted. + white, clumpy, thick vaginal
discharge. Parous cervix noted with no discharge. Small 1-2 mm yellow/white
smooth lesion at 2 o’clock position. Negative CMT, no masses/tenderness of
adnexa.
Grading Guide: Case Study Paper
The paper is 15-20 pages (not including cover page, references, and appendices) using
APA 7th edition. This paper should include the holistic patient scenario, including other
medical issues to address. The APRN is the primary caregiver for this patient.
1.) Provide an overview of the case study:
• History
• Physical Assessment
• Discuss pertinent positive findings and pertinent negative findings
• Special considerations (age, race, co-morbidities, others?)
• Additional history questions
15%
2.) Analyze lab data available for this patient and indicate additional
laboratory tests you would order.
• Discuss what existing lab values mean
• Discuss what other laboratory studies, special tests, diagnostics
you would order with rationale!
This section should cover what you would order for the patient based on
ALL aspects of care, not just the chief complaint.
15%
3.) Support your diagnostic reasoning as you compare 2-3 most likely
diagnoses for the chief complaint of the patient only.
• Demonstrate critical thinking as you arrive at the probable
diagnosis, explaining your rationale for consideration and how to
rule in/out.
15%
4.) In 2-3 paragraphs, provide a brief overview of this disease state (s)
• Epidemiology
• Causes
• Pathophysiology
10%
5.) Discuss a plan of care for this patient, covering all aspects of her
healthcare:
• Medical: Medications, tests, other therapies, etc. For prescribed
medications, include mechanism of action, options, dosing,
contraindications, common side effects, and other important
considerations when prescribing/monitoring this medication (or
class of medication.
• Patient care/education – covering all aspects of care, what
teaching should be provided to this patient?
• Potential complications of the chief complaint and other presenting
medical issues, and how this influences your follow up and/or
referrals. What referrals might you consider?
• Health promotion and screening applicable to this patient,
including USPSTF recommendations and vaccinations to discuss.
25%
6.) Appendix: Document the patient encounter as a SOAP note that
matches your text that would be suitable for entry into a patient’s chart or
healthcare record.
• Do not make up any history unknown, assume as normal or not
done. Show the PE write up you would document for this patient
with symptoms and history discussed.
10%
7.) Proofreading, organization, grammar, APA format
• Comprehensive review of recent EPB/literature
• Multiple, varied, and scholarly references
10%
= 100%
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