NRNP 6552 Week9 Case Study Assignment: Teresa
Case #1. Teresa.
History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your office today at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure to progress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital on day 2 post-partum without complications. Teresa has had difficulty with breast feeding due to discomfort in her suture line and terrible pain in her right breast since her discharge from the hospital.
She reports occasional chills- she has not measured her temperature at home. Teresa was seen by the lactation consultant while in the hospital but “nothing is working” and her son “cries all the time”. She is afraid to feed her son formula as her mother-in-law wants her to “keep trying to breastfeed”. Teresa tells you she feels as if she has failed her son- “it was so easy with my first baby, I know my husband thinks I am a bad mother”.
Prior medical history: None. Prior surgical history: Appendectomy (2000)
Current medications: Prenatal vitamins, stool softener. Allergies: None
OB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.
Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history of sexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by a normal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.
LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history:
Oral contraceptives, condoms.
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Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH or
recreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.
Family history: Unremarkable.
Review of Systems (ROS): Negative except as noted in HPI.
Physical Exam (PE)
VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.
Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge or lesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam, you do note an erythematous, swollen, and painful area to the right breast. Her physical exam is otherwise unremarkable.
Case Study Teresa
| Outline Subjective data.
Identify data provided in your chosen 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 your chosen case. |
Describe collaborative care referrals and patient education needs for your chosen case.
Describe rationales and supporting references for each.
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NRNP 6552 Week9 Case_Study Assignment
| NRNP_6552_Week9_Case_Study_Assignment_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomeAnalyzes subjective and objective data and outlines applicable diagnostic tests related to case studies. |
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30 pts | ||||
| This criterion is linked to a Learning OutcomeIdentifies differential diagnoses related to case studies. |
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30 pts | ||||
| This criterion is linked to a Learning OutcomeFormulates a treatment plan related to case studies based on scientific rationale, evidence- based standards of care, and practice guidelines. Integrates ethical, psychological, physical, financial issues and Social Determinants of Health in plan. |
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30 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation |
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5 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. |
|
5 pts | ||||
| Total Points: 100 | ||||||