History of Present Illness (HPI): Nadine is a 22-year-old female G0 who presents for a well
woman exam.
She is interested in starting birth control. She is sexually active with her boyfriend; they do
not use
condoms.
Prior medical history: Sickle cell trait, Systemic lupus erythematosus (SLE),...
History of Present Illness (HPI): Nadine is a 22-year-old female G0 who presents for a well
woman exam.
She is interested in starting birth control. She is sexually active with her boyfriend; they do
not use
condoms.
Prior medical history: Sickle cell trait, Systemic lupus erythematosus (SLE), Pulmonary
embolism,
Dysmenorrhea. Prior surgical history: None
Current medications: Plaquenil, Cellcept, prednisone, lisinopril, Eliquis, atorvastatin,
omeprazole.
Allergies: None
OB- GYN History: Menarche age 12, cycle length-5 days- frequency every 28 days- 3
tampons per day.
History of chlamydia in the past year. Has received Human Papillomavirus (HPV) vaccine
series.
LMP: 3 weeks ago. Contraception history: Withdrawal
Social history: Lives with her sister. Denies EtOH or recreational drug use. Vapes daily.
Does not
exercise. Poor diet – fast food and sodas.
Family history: Mother alive – sickle cell. Father alive - HTN.
Review of Systems (ROS): Unremarkable.
Physical Exam (PE)
VS: BP: 133/68, P: 87, RR: 18, T: 98.2 Weight: 188 lbs., Height 64”, BMI 32.3
Lab – urine pregnancy test negative
General: Obesity in female. Oriented x 3. Pleasant.
Integumentary: Warm, dry, and intact.
Abdomen: Soft, NTND, BS present x 4.
External: Appropriate hair distribution, No lesions or erythema. Speculum exam: No
discharge, no
lesions, no cervical motion tenderness (CMT). Bimanual exam: uterus normal size firm and
non-tender.
No adnexal masses palpated bilaterally, nontender. Breast exam normal.
Outline Subjective data.
Identify data provided in this case and any additional data needed.
Outline Objective 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 key
Social Determinants of Heath (SDoH) for this case
Describe collaborative care referrals and patient education needs for this case
Describe rationales and supporting references for each.
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