Order Description
write a 3- report on the case you presented in the W7 Assignment 3 (pasted bellow) . When constructing your report, use the same format (link for the format) https://threadcontent.next.ecollege.com/pub/content/9be5cb01-eab2-4260-8963-237dd5272622/SU_NSG6330_W7_A3_Format.pdf
Assignment 4 Grading Criteria
Maximum Points
Submitted a 3- report on the case presented in W7 Assignment 3.
5
Completed the initial assessment.
2
Provided an appropriate and complete list of differential diagnoses.
2
Supported final diagnosis with testing, test results, and other findings (and ruled out other possible diagnoses).
2
Described a plan that appropriately addresses all actual diagnoses.
2
Provided an evaluation and reflection on the implementation and results.
5
Used correct spelling, grammar, and professional vocabulary and cited all sources using APA style.
2
Total:
20

Name: D.D.

Date: 03/28/2016

Time: 1130

Age: 25 years

Sex: female

SUBJECTIVE

CC:

“8 week postpartum exam before I go back to work”

HPI:

Pt delivered a healthy baby girl 8 weeks ago. Vaginal delivery with no tears. She was induced. Labor was 7 hours. This is her second pregnancy, second delivery. She received an epidural for delivery. She is currently breastfeeding without complications. She was prescribed birth control pills at discharge and desires tubal ligation for permanent sterility.

Medications: not currently taking medications. Has prescription for:

Iron- for anemia

Mini-pill- for birth control

Tylenol- as needed for pain

Ativan- for anxiety

PMH: Pt has history of depression and anxiety. Pt was sexually assaulted during training away from her husband. Pt has some question of the paternity of her new child. Husband is unaware of assault or paternity questions. Pt was referred to Sexual Assault/Victim’s advocate program. She reported assault over a month after event, no physical evidence could be obtained. Pt was referred to Behavioral Health for counseling and support. Pt does not reference assault or paternity questions when husband present. Is very quiet when husband is in the room. He answers more questions for her. Pregnancy was full term without complications.

Allergies: NKA

Medication Intolerances: N/A

Chronic Illnesses/Major traumas- sexual assault 2014

Hospitalizations/Surgeries- two childbirths, vaginal deliveries

Family History

Pt knows some relatives have had breast cancer, but does not know age. Husband states it is a paternal aunt and grandmother had cancer. Pt does not know heart history of family.

Social History

Active duty soldier, married with two children. 12+ year education. Denies smoking, drinking, or drug use.

ROS

General

Pt has lost 30 lbs since delivery. Pt gained 20 lbs during pregnancy, has dropped additional 10 lbs. Pt doesn’t have an appetite. Eats once a day and snacks or has smoothies. Trouble sleeping, often tired.

Cardiovascular

Denies

Skin

Denies

Respiratory

Denies

Eyes

denies

Gastrointestinal

denies

Ears

denies

Genitourinary/Gynecological

Denies urgency, frequency burning, change in color of urine.

Contraception-pills

Not sexually active yet postpartum, no STDS

Fe: last pap 2014, no breast complaints, vaginal discharge- spotting still from delivery, 2 pregnancies, 2 deliveries

Nose/Mouth/Throat

denies

Musculoskeletal

Sciatic nerve pain, IT band syndrome L leg, bone trauma to L leg

Breast

denies

Neurological

denies

Heme/Lymph/Endo

denies

Psychiatric

Depression, anxiety, sleeping difficulties, denies suicidal ideation/attempts

OBJECTIVE

Weight 172 lbs BMI 29.52

Temp 97.7

BP 110/70

Height 64 inches

Pulse 84

Resp 18

General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, quiet, and withdrawn. Nursing infant daughter. Looks to husband frequently during questions

Skin

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. Ears: Canals patent.Nose: Nasal mucosa pink. No septal deviation. Neck: Supple. Full ROM. Oral mucosa pink and moist. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen flat; BS active in all 4 quadrants. Abdomen soft, non-tender.

Breast

Breast is free from masses or tenderness, no abnormal discharge. Lactating. No signs of engorgement. R breast has small lumps, milk ducts full. L breast soft and no lumps, infant nursed from that breast during visit. Nipples are intact, no cracking, bleeding, or signs of infection.

Genitourinary

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable.

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room. Pt c/o chronic left leg pain. No palpable deformities, cap refill brisk, and pedal pulse strong in LLE.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean jeans and a tank top. Does not maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Defers to her husband to answer most questions. Admits to being depressed and anxious. Has lost 30 lbs because she has no appetite. She is afraid to take her anti-anxiety medication because she is breastfeeding and doesn’t want to hurt the baby.

Lab Tests

N/A

Special Tests

ASSESSMENT FINDINGS AND PLAN

Diagnosis
1. Postpartum depression
2. Depression related to trauma
3. Anxiety related to sexual assault
Plan:
Referred patient to continue with Behavioral Health for counseling and treatment of depression and anxiety. Also referred patient to orthopedics for chronic left leg pain to resume care since she has delivered her child.
Prescribed Zoloft, which is safe to take while breastfeeding and encouraged patient to take it daily at time to assist her with insomnia, as well as depression and anxiety
Follow up with patient in two weeks to see if Zoloft is reaching the desired effects and to ensure symptoms are not worsening, or that suicidal or homicidal ideations are not beginning.
References

Goolsby, J., & Grubbs, L. (2014) Advanced assessment: Interpreting findings and formulating differential diagnoses, 3rd edition,
3rd Edition. F.A. Davis Company. VitalBook file.