NURS664B Primary Care Women's Health Theory
Week 1 Discussion
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #2 a post-menopausal 57-year old woman.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas. Please refer to evidence-based guidelines to support your decision-making.
In your peer replies, please reply to at least one peer who chose a different case study.
1. A 29-year-old woman G0P0 comes to your clinic and complains of trying to conceive with her husband for over a year. She reports no prior health problems or surgeries. Her height is 5'6" and her weight is 165 lbs. with a BMI of 26.63. Her vital signs are WNL. Her LMP was 2 months ago, but she reports they have never really been regular since menarche (coming approximately every 6 weeks for the first 10 years), but have been irregular (coming at random intervals—sometimes 1 month, 2 months, or 3 months apart) for approximately 7 years. Her pregnancy test is negative. Upon physical examination, you note some acne and hirsutism on her face, as well as acanthoses nigricans on her neck. All other physical exam aspects are WNL.
What are your differential diagnoses?
What is your plan of care, and why?
What patient education is pertinent during this visit?
2. A post-menopausal 57-year-old woman complains of intermittent, slight vaginal bleeding and vague pelvic pain unrelated to intercourse that has been occurring for approximately four months. She has been post-menopausal for five years and denies other health problems. Her vital signs are all WNL. She does not take any medications or hormones.
What additional information do you need to obtain?
What are your differential diagnoses?
What is your plan of care, and why?
3. A 58-year-old woman presents for her annual well-woman examination. She reports that she started having (vaginal) spotting about 3 months ago, “I thought maybe I was having one last period,” and has had increased urinary frequency over the past 2 to 3 months. She denies any constitutional symptoms, and denies pelvic pain. Her past medical history is notable for hypothyroidism, hypercholesterolemia, hypertension, and type II diabetes. Family history is notable for father with lung cancer, mother with uterine cancer, and maternal first cousin with colon cancer. She is obese but is exercising regularly. She reports one abnormal Pap smear about 15 years ago, which was worked up, and “normalized” after follow-up Pap smears without any surgery. Her last Pap smear was about 4 or 5 years ago and she recalls it was negative; she was told that she didn’t have to have any more Pap smears. She went through menopause at 54 years of age, used combination hormone replacement therapy (HRT) for 2 to 3 years, discontinued 2 years ago. Vital signs: Height 158 cm; Weight 78.0 kg; BMI 31.2; BP 148/88 mmHg; Pulse 84; Respirations 18; Temp 36.6°C. Physical exam notable for normal cardiovascular, respiratory, skin, musculoskeletal; abdomen obese, soft, non-distended, non-tender; pelvic exam notable for normal female genitalia, no lesions; vagina and cervix normal, no discharge or blood in vaginal vault; bimanual exam notable for no tenderness on exam; uterus somewhat globular, approximately 10 to 12 weeks size; ovaries non-palpable.
Which test/study will you want to obtain first?
Which risk factor contributes most to this woman’s risk for endometrial cancer?
The results of the endometrial biopsy return as endometrioid adenocarcinoma FIGO grade I to II. What will you want to do next?
What suggestions can you give her to improve her successful post-hysterectomy adjustment?
NURS664B Primary Care Women's Health Theory
Week 2 Discussion
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #2 a post-menopausal 57-year old woman.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas. Please refer to evidence-based guidelines to support your decision-making.
In your peer replies, please reply to at least one peer who chose a different case study.
1. A 19-year-old female comes to your clinic complaining of severe menstrual pain that is usually worse just prior to and during the first two days of her menses. The pain is sometimes so severe that she has fainted. She states that defecation can cause severe pain and she therefore frequently becomes constipated. She often must miss work when experiencing the severe pain. Her periods are heavy and last seven days with a tapering of the bleeding from days 3 to 7. Her BMI is 23.9 and her VS are all WNL. She is G0 P0.
What additional history do you need to ask this patient?
What are your differential and presumptive diagnoses?
How will you manage this patient, and why?
2. A 35-year-old African American female comes to the clinic complaining of pelvic pain that started as intermittent, but now is almost constant. She also complains of irregular vaginal bleeding/spotting that has occurred in between her monthly menses for the last six months. She has no family history of breast or ovarian cancer. Her vital signs (VS) and BMI are all within normal limits (WNL), but upon physical examination, you palpate a firm, raised area on her uterus. You note no cervical motion tenderness (CMT), no adnexal tenderness (AT), and no other abnormalities. She is G2 P2 with both normal spontaneous vaginal deliveries (NSVD) 10 and 8 years ago.
What are your differential and presumptive diagnoses?
Explain the pathophysiology of your presumptive diagnosis.
What test(s) will you order to confirm the diagnosis?
What is your plan of care for this patient?
3. A 20-year-old nulliparous female presents to student health with complaints of chronic pelvic pain. She shares that she has always had painful periods. She has taken OCs in the past to help with the pain but stopped secondary to side effects of weight gain. She adds that she only has sex with females and does not need birth control. Her LNMP was 2 weeks ago. Her pelvic exam reveals uterosacral nodularity. Abdominal exam is negative. Height 5'7", weight 120, and BP 132/78.
What additional history do you need from this patient?
What is your differential diagnosis?
What laboratory tests do you need and why?
What is your plan of care?
NURS664B Primary Care Women's Health Theory
Week 3 Discussion
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #2 a post-menopausal 57-year old woman.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas. Please refer to evidence-based guidelines to support your decision-making.
In your peer replies, please reply to at least one peer who chose a different case study.
1. A 41-year-old female complains of a small lump she feels in her right breast. Upon physical examination, you palpate an approximately 2x2 cm firm, non-tender, immobile mass in the right upper outer quadrant of the right breast at approximately 10 o’clock, 1 cm above the areola.
What additional information is needed from this patient?
What are your differential diagnoses?
What are your next steps and plan of care for this patient, and why?
2. A 36-year-old female complains of rapid swelling of her left breast over the last month with an orange peel type texture to the skin of that breast and a rash that does not respond to topical creams.
What concerns you the most about this patient presentation?
What are your differential diagnoses for this patient?
What is your plan of care, and why?
3. A 31-year-old G0 P0 female complains of mastalgia. She reports it is intermittent and sometimes she thinks she feels lumps in the outer quadrants of her breasts. She has no family or personal history of cancers, she menstruates regularly, is not pregnant, and uses condoms consistently for BCM and STI protection.
What additional information do you need from this patient?
What information is most important in determining whether this is a potentially serious or benign issue?
Describe the steps in assessment of mastalgia.
Describe any recommendations you would provide for this patient.
NURS664B Primary Care Women's Health Theory
Week 4 Discussion
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #2 a post-menopausal 57-year old woman.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas. Please refer to evidence-based guidelines to support your decision-making.
In your peer replies, please reply to at least one peer who chose a different case study.
1. A 49-year-old woman comes to the clinic complaining of an itching and scaling over her left nipple for two months that has not cleared with the topical creams she was provided for dermatitis.
What are your differential diagnoses?
What is your working diagnosis, and why?
What is your plan of care?
2. A 28-year-old woman tells you her mother was diagnosed with ovarian cancer at age 42 and her 35-year-old sister has just been diagnosed with breast cancer. She asks you if there is anything she should be doing to screen for and assess her own risk for breast and ovarian cancers. However, she tells you that she does not carry health insurance.
What do you advise this patient based on current recommendations for screening for potential genetically inherited mutation cancers?
What options would you consider for this patient who does not carry any type of health insurance?
3. A 50-year-old female complains of spontaneous nipple discharge from her left nipple. She has no personal or family history of cancers. She is G3 P3, all uncomplicated pregnancies and vaginal deliveries. She continues to have regular menses and is not pregnant.
What additional information do you need to ask this patient?
Describe the most likely benign and pathologic conditions (one of each) that could be causing this symptom.
What are your treatment options?
NURS664B Primary Care Women's Health Theory
Week 5 Discussion
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #2 a post-menopausal 57-year old woman.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas. Please refer to evidence-based guidelines to support your decision-making.
In your peer replies, please reply to at least one peer who chose a different case study.
1. A 48-year-old female complains her menstrual cycle has recently become irregular, and she is experiencing hot flashes. She has also noticed a decrease in her desire for sex lately. She has been married to a man for 20 years, is in a stable relationship, and has two daughters ages 16 and 18. She is otherwise healthy with an unremarkable medical history. Her pregnancy test is negative. Her Pap smear and STI panel are all negative.
What are your presumptive and differential diagnoses?
What test(s), if any, will you order to confirm your diagnosis?
What is your plan of care for this patient?
2. A 53-year-old woman comes to the clinic complaining of vaginal dryness that is so bothersome that it makes intercourse attempts very painful. She has been unable to have intercourse for the last year because of it. She denies vaginal bleeding and has been postmenopausal since age 51. Her VS are WNL, but her BMI is 27 and she reports she has gained 30 pounds over the last three years without any changes in her diet or activity levels from her 40s. Her PE is unremarkable except for noted vaginal atrophy and dryness
What are your presumptive and differential diagnoses for this patient?
What is your plan of care, and why?
3. A 43-year-old G3 P3 White female presents complaining of hot flashes, amenorrhea for 4 months, and then this month she had spotting for 3 days. She has breast tenderness, vaginal itching, and dyspareunia. Her husband had a vasectomy 20 years ago. She wants to know what she can do for relief. Her last Pap was 2 years ago and was negative. Her last MMGM was 5 years ago and was negative. FSH is 39. Height 5' 8", weight 145 lbs.
What is your differential diagnosis?
What is your plan of care?
What complementary therapies might be helpful for this patient? Support with evidence-based literature.
NURS664B Primary Care Women's Health Theory
Week 6 Discussion
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #2 a post-menopausal 57-year old woman.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas. Please refer to evidence-based guidelines to support your decision-making.
In your peer replies, please reply to at least one peer who chose a different case study.
1. A 63-year-old woman complains of frequency and burning with urination for the last two days that is worsening. No CVAT, no flank pain, afebrile, and no remarkable findings upon PE.
What is your presumptive diagnosis?
What is your rationale for choosing the presumptive diagnosis?
What is your plan of care?
2. A 59-year-old woman G7P7 all uncomplicated NSVDs, complains of inadvertently urinating on herself whenever she coughs, sneezes, or heartily laughs. It has been happening intermittently since the birth of her last 3 children, but it now happens so often that she must wear a sanitary pad, and she is afraid there can be an odor at times. She asks you what, if anything, can be done to alleviate this that does not have to entail having surgery.
What type of urinary continence is this woman experiencing?
What is the pathophysiology?
What will you recommend for this patient?
3. A 65-year-old woman complains of a heavy sensation in her vagina for the last 3 years that started mildly and has progressively worsened so that she now feels “something at the entrance.” Upon physical exam, you note that her cervix is just above (inside) the vagina about 1 to 2 centimeters.
What is your presumptive diagnosis?
What is your rationale for choosing the presumptive diagnosis?
What type (s) of treatments will you educate your patient on?
NURS664B Primary Care Women's Health Theory
Week 7 Discussion
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #2 a post-menopausal 57-year old woman.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas. Please refer to evidence-based guidelines to support your decision-making.
In your peer replies, please reply to at least one peer who chose a different case study.
1. A 25-year-old woman comes to your office for her first Pap smear exam. She tried to have a Pap smear before, but she was unable to tolerate insertion of the speculum. She cannot use tampons during her menses due to pain at her introitus when she tries to insert the tampon. Her last boyfriend broke up with her after 6 months because she was unable to have intercourse with him due to pain at her introitus when trying to insert his penis. The patient cannot remember exactly when this pain started because she didn’t attempt to use tampons until she was 19 years old. She did not attempt intercourse until she was 21 years old. She thinks she noticed this pain the first time she attempted to insert a tampon but cannot be sure. She is extremely anxious and almost in tears about the thought of having a Pap smear, but thinks she “must” have one even though she reports being unable to ever have vaginal intercourse.
How will you approach this patient?
What types of intervention will you attempt to use?
What are your presumptive (describe physiology and pathophysiology) and differential diagnoses?
What is your plan of care for this patient?
2. A 21-year-old patient complains of being unable to achieve orgasm with any type of sexual activity. She does not believe she has ever achieved orgasm. She reports she has no difficulty with desire, lubrication, or pain, and she has tried different types of sexual toys. Her partner of three years has been supportive and has tried many different positions to try to help her to achieve orgasm.
What are your differential/presumptive diagnoses for this patient?
What is your plan of care?
3. J. R. is a 55-year-old female who complains of poor vaginal lubrication, lack of genital tingling, and not feeling “turned on” by her partner during sexual activity. She looks forward to sexual activity with her partner and is receptive; however, once they are together, she is unable to become aroused. She is orgasmic. She also complains of daily hot flashes and night sweats. A typical sexual encounter occurs once weekly. There is adequate foreplay, sufficient privacy (the children are grown and are out of the home), and they are well rested. However, J.R. always has to use a lubricant and still experiences some dyspareunia during intercourse.
Her last menses was 2 years ago. Her medical history is significant for hypertension, well-controlled on a beta blocker (Inderal 120 mg twice a day), and hypothyroidism, controlled with levothyroxine (Synthroid 0.1 mg daily). She has had two vaginal deliveries. She does not drink alcohol or smoke. Her family and personal medical and psychiatric history are negative.
What medical conditions are most commonly associated with development of female sexual dysfunction?
Which medications are most likely to induce female sexual dysfunction?
What treatment would you recommend?
NURS664B Primary Care Women's Health Theory
Week 8 Discussion
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #2 a post-menopausal 57-year old woman.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas. Please refer to evidence-based guidelines to support your decision-making.
In your peer replies, please reply to at least one peer who chose a different case study.
1. A 23-year-old female comes to your office with vague vaginal complaints. She reports that sometimes intercourse is uncomfortable, and sometimes she notices a little whitish-clear non-odorous vaginal discharge midway through her cycle. But none of her complaints supports a vaginal infection/STI or other organic pelvic condition diagnosis. You notice this patient has bruising on her back and both arms.
Please write the specific questions you will ask this patient in layperson’s terms.
What is your plan of care?
2. A 46-year-old female G5 P3 comes to your office for her annual physical exam. On her intake paperwork, you note she selected the “have sex with females” box and did not select the “have sex with males” box in her sexual history.
What additional questions should you ask your patient so that you can provide her with comprehensive, patient-centered care?
How will you sensitively handle the topic of birth control?
What is your plan of care for this patient?
3. A 49-year-old woman is concerned that her partner of the same sex and age no longer initiates sexual activity. Her partner has been experiencing irregular menses and low energy for the past year. Nothing seems to stimulate her partner as it used to. When the woman extends foreplay to give her partner more time to respond, she does not respond as before, and it is beginning to affect their relationship because they do not communicate like they used to.
What are your presumptive and differential diagnoses?
What patient education will you provide for this patient?
NURS664B Primary Care Women's Health Theory
Week 7 Case Study Paper
Choose one of the cases below for your report and include the following:
A thorough understanding of the topic
A critical assessment of all questions
At least two differential diagnoses, if applicable
At least two pharmacologic treatment modalities, if applicable
A well-developed treatment plan
A thorough patient education plan
The body of your paper needs to be 3-4 pages long. This does NOT include the title page and reference page. Papers that are more than 4 pages long will not be accepted. You must reference a minimum of two scholarly sources on your paper.
Use current APA format to style your paper and to cite your sources. Integrate your sources into the paragraphs and use internal citations pointing to evidence in the literature and supporting your ideas.
Be sure to allow time for editing and proofreading.
Review the rubric for more information on how the assignment will be graded.
Case Study #1: Sexual Health, Gynecologic Care for Sexual and Gender Minorities
Mary, a 32-year-old, G0P0, female who identifies as lesbian, presents with c/o vaginal discharge that has a strong fishy odor. She has tried douching and over-the-counter remedies with no relief. She shares that she and her girlfriend use sex toys. She denies having sex with anyone else, but she says her girlfriend is bisexual and possibly has been with someone else. She says she has only had one pelvic exam when she was 20 years old, with a male physician, and she felt as though she had been raped. During the examination, he was rough and she could tell he did not like the fact that she identified as lesbian. She has not been seen since. She denies any health issues in her past, has never been pregnant, has never had sex with males, and has never had an STI, or at least she believes she has not. She also shares that she is very nervous but knew she had to come in.
1. Prior to your exam, how will you address her fear?
2. What other historical information will you obtain?
On exam, her height is 5' 8", weight 165lbs, BP 118/76, breast exam negative, pelvic exam reveals thin homogenous, frothy green discharge pooling in the posterior fornix. Negative cervical motion tenderness, negative adnexal tenderness, and her uterus is normal size, shape, and contour with no tenderness on palpation. Her cervix is normal but bleeds easily with manipulation.
3. What are your differential diagnoses? What is your final diagnosis?
4. What additional tests will you order and why?
5. Based on your final diagnosis, what is your treatment plan?
6. What educational issues do you want to discuss with this patient.
Case Study #2: Gynecologic Abnormalities
Gladys, a 75-year-old woman, G5P5, presents for an annual exam and reports a “fullness” in her vagina. She notices her symptoms more when she is standing for a long time. This feeling is bothersome and is affecting her daily activities. She does not complain of urinary or fecal incontinence. She has not experienced any vaginal bleeding. Her past medical history is significant for well-controlled hypertension and chronic bronchitis. She has never had surgery.
Pelvic exam reveals normal appearing external genitalia except for generalized atrophic changes. The vagina and cervix are without lesions. Relaxation of the anterior and posterior vaginal wall is noted to approximately one centimeter beyond the vaginal opening when she is asked to Valsalva. The cervix also descends to that level with Valsalva. The uterus is normal size. The ovaries are not palpable. No rectal masses are noted. Rectal sphincter tone is slightly decreased.
1. What are the most important support mechanisms for the pelvic organs?
2. What increases this patient’s risk for pelvic organ prolapse?
3. What are the different types of pelvic organ prolapse?
4. What are the steps in evaluating someone with prolapse?
5. What are treatment options you should discuss with this patient?
6. When is surgery indicated for prolapse?
Case Study #3: Gynecologic Abnormalities
Mrs. Jones, a 42-year-old, G3P3, presents with a history of abnormal bleeding and pelvic pain. She was well until approximately age 35, when she began developing dysmenorrhea and progressive menorrhagia. The dysmenorrhea was not fully relieved by NSAIDs. Over the next several years, the dysmenorrhea and menorrhagia became more severe. She then developed intermenstrual bleeding and spotting as well as pelvic pain, which she describes as a constant feeling of pressure. She also complains of urinary frequency. Her past GYN history is negative. Her surgical history includes 3 C-sections and a bilateral tubal ligation at age 30. Her past medical history is unremarkable.
Her physical exam reveals a well-developed, well-nourished woman in no distress. Vital signs and general physical exam are unremarkable. Her abdominal exam reveals an irregular-sized mass extending halfway between the symphysis pubis and umbilicus deviated to the right of the midline. The vagina and cervix appear normal on inspection. However, the cervix palpates firm. The uterus is markedly enlarged and irregular, especially on the right side. The adnexae are not palpable.
Labs drawn: Hgb. 10.3 Hct. 31.2%. Indices are hypochromic, microcytic. Serum ferritin confirms mild iron deficiency anemia. Pap test is negative and an ultrasound reveals multiple large intramural fibroids, filling the pelvis and extending into the lower abdomen. The ovaries are not visualized.
1. What are the likely causes for the mass?
2. What are your differential diagnoses? What is your final diagnosis?
3. What is the prevalence of leiomyoma in different populations of women?
4. Discuss the appropriate management of women with fibroids.
5. What are the indications for hysterectomy in women with fibroids?
6. What are nonsurgical treatment options for women with fibroids?
