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Assignment NR 602 Week 7 Clinical Case- Heavy Menses

Assignment: NR 602 Week 7 Clinical Case- Heavy Menses

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CC: Patient is complaining of irregular heavy menses with severe cramping

HPI: EM, 21 yo Hispanic G0 female presented for establishment of gynecological care. Pt is not sexually active. Her first menstrual period was at age 11. She has been on OCP since 17 yo due to her dysmenorrhea. Pt with irregular and heavy periods (accompanied with heavy cramping) that will come every 2-3 weeks. LMP started 9/5/17. She has never had a papsmear. She is currently on Ortho Tri-Cyclen for her dysmenorrhea for the past 2 years. Pt reports continued irregular and heavy menstruation. She has tried 3-4 other OCPs with little success. She has also tried Depot shots. Pt on iron supplementation for the past year after having to report to the ER in 2016 for heavy uncontrollable menses.

Pt reports increased fatigue, weight gain, dry skin, hair changes, polydipsia, nocturia, polyuria, and constipation.

She denies palpitations, dizziness, HA, SOB, CP, edema.

She has not had her labs checked besides her CBC in the ER in 2016

Pt with developmental delay, functions at 15 yo level per mother

Current medications: Ortho Tri Cyclen Lo daily for heavy menses

Ferrous Sulfate 325mg take once daily for anemia

 

Allergies: NKA

Medical Hx: Start of menarche at age 11

Up to date on all vaccinations

Developmental Delay

Iron Deficiency Anemia

Menorrhagia

Dysmenorrhea

NR 602 Week 7 Clinical Case- Heavy Menses

Social Hx:

Single, not currently sexually active

Non-smoker. Denies alcohol or illicit drug use

Occupation: Assists with afterschool program

 

Family Hx:

Father- prediabetes, High cholesterol

Maternal grandpa- DM

Maternal grandma- DM, CKD on HD

Paternal grandma- HTN

Paternal grandpa- HLD

Assignment NR 602 Week 7 Clinical Case- Heavy Menses

Assignment NR 602 Week 7 Clinical Case- Heavy Menses

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ROS

General: Reports fatigue and weight gain, unexplained weight or weight loss, loss of appetite, fever, night sweats. Does report dry hair and hair changes

EENT: Denies difficulty hearing, sinus problems, runny nose, ear pain, facial pain or numbness

CV: Denies irregular heartbeat, racing heart, chest pain, swelling to feet or legs, pain in legs with walking

Resp: Denies shortness of breath, night sweats, cough, wheezing, sputum production

GI: Denies heartburn, constipation, diarrhea, abdominal pain, difficulty swallowing, nausea, vomiting, bloody stools, change in bowel habits

GU: Denies painful urination, frequent urination, urgency

MS: Denies joint pain, aching muscles, swelling in joints, joint derformities or back pain

Skin:  Reports dry skin. Denies rash, itching, lesions or breast changes

Neuro: Denies headaches, double vision, weakness, change in sensation, dizziness, tremor, loss of consciousness

Psych: Denies insomnia, irritability, depression, anxiety, recurrent bad thoughts, mood swings, hallucinations, compulsions

Endocrine: Denies intolerance to heat or cold, reports irregular heavy cycles accompanied with severe cramping. Reports increased thirst, urination, constipation

Hematologic: Denies easy bleeding, easy bruising, anemia, abnormal blood tests, leukemia

NR 602 Week 7 Clinical Case- Heavy Menses

Objective

General: Normotensive, in no acute distress.

Head: Normocephalic, no lesions.

Neck: Supple, no masses, no thyromegaly, no bruits.

Chest: Lungs clear, no rales, no rhonchi, no wheezes.

Heart: RR, no murmurs, no rubs, no gallops.

Abdomen: Soft, no tenderness, no masses, BS normal.

Extremities: Warm, well perfused, no edema.

 

Diagnostics

TSH, FT4, CBC, Iron panel, A1C, CMP, lipid panel

Important information for writing discussion questions and participation

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

  • Your response needs to be a minimum of 150 words (not including your list of references)
  • There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
  • Include in-text citations in your response
  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

  • A minimum of 6 responses per week, on at least 3 days of the week.
  • Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
  • Each response needs to be at least 75 words in length (does not include your list of references)
  • Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
  • Follow APA 7th edition
  • Points will be deducted if the above is not followed

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to.

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

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