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– ## casestudywk3.docx
**## casestudywk3.docx**
Gynecologic Health
Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, diagnostic approaches, as well as the development of treatment plans.
For this Case Study Assignment, you will analyze a case study scenario to obtain information related to a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop treatment and management plans.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
[**WEEKLY RESOURCES**](https://waldenu.instructure.com/courses/185284/modules/items/7612942)
**To prepare:**
· Review the 4 case studies in this week’s Learning Resources. Select one of the cases to prepare your written assignment.
· Review the Learning Resources for this week and pay close attention to the media program related to the basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources.
· Carefully review the clinical guideline resources.
**Assignment Instructions:**
· Use the Case Study Template from the Learning Resources to complete the assignment. Your submission must include a brief case write-up, followed by the fully completed template, which must be integrated into the document rather than submitted separately.
· Include a title page, a case summary in your own words, the completed template, and a reference page formatted in APA style.
· Ensure your submission meets all criteria outlined in the template and rubric for completeness and accuracy.
By Day 7 of Week 3
**Submit** your case study assignment by
**Day 7 of Week 3**.
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the
**Turnitin Drafts** from the
**Start Here** area.
1. To submit your completed assignment, save your Assignment as
**Wk3Assgn_LastName_Firstinitial**
2. Then, click on
**Start Assignment** near the top of the page.
3. Next, click on
**Upload File** and select
**Submit Assignment** for review.
Rubric
**NRNP_6552_Week3_Case_Study_Assignment_Rubric**
| | | |
| — | — | — |
| NRNP_6552_Week3_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. | **30 to >26.7 ptsExcellent** The response provides clear, complete, and comprehensive descriptions of subjective and objective case data, appropriately outlining all diagnostic tests, clinical procedures and pharmacological interventions.<br> <br>**26.7 to >23.7 ptsGood** The response provides clear, complete partial descriptions of the components of the subjective and objective case data, appropriately outlining most of the diagnostic tests, clinical procedures and pharmacological interventions.<br> <br>**23.7 to >20.7 ptsFair** The response provides some components of the subjective and objective case data, but they are incomplete, vague or inaccurate, outlining some of the diagnostic tests, clinical procedures and pharmacological interventions.<br> <br>**20.7 to >0 ptsPoor** The response provides unclear or incomplete components of subjective and objective case data. The diagnostic tests, clinical procedures and pharmacological interventions are missing, incorrect, or inappropriately applied. | 30 pts |
| This criterion is linked to a Learning OutcomeIdentifies differential diagnoses related to case studies. | **30 to >26.76 ptsExcellent** The response contains at least 3 differential diagnoses relevant and applicable to the case.<br> <br>**26.76 to >23.7 ptsGood** The response contains at least 2 differential diagnoses relevant and applicable to the case.<br> <br>**23.7 to >20.7 ptsFair** The response contains at least 1 differential diagnosis relevant and applicable to the case.<br> <br>**20.7 to >0 ptsPoor** The response contains few or no differential diagnoses and/or diagnoses are not relevant and applicable to the case. | 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. | **30 to >26.76 ptsExcellent** Formulates a thorough treatment plan including explanations of appropriate diagnostic tests and treatment options. Fully incorporates syntheses representative of knowledge gained from the resources for the module and current credible sources, with no less than 75% of the treatment plan having exceptional depth and breadth. Supported by at least 3 current peer- reviewed, references or professional practice guidelines.<br> <br>**26.76 to >23.7 ptsGood** Formulates a partially complete treatment plan including partial explanations of appropriate diagnostic tests and treatment options. Somewhat incorporates syntheses representative of knowledge gained from the resources for the module and current credible sources with no less than 50% of the treatment plan having exceptional depth and breadth. Supported by at least 3 current peer- reviewed, references or professional practice guidelines.<br> <br>**23.7 to >20.7 ptsFair** Formulates a minimally complete treatment plan including incomplete or vague explanations of appropriate diagnostic tests and treatment options. Lacking in synthesis of knowledge gained from the resources for the module and current credible sources. Supported by at least 2 current peer- reviewed, references or professional practice guidelines.<br> <br>**20.7 to >0 ptsPoor** Formulates a treatment plan that contains incomplete explanations of appropriate diagnostic tests and treatment options and/ or explanations are missing. Lacks synthesis gained from the resources for the module and current credible sources. Supported by 1 or no current peer- reviewed, references or professional practice guidelines. | 30 pts |
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards:<br>Correct grammar, mechanics, and proper punctuation | **5 to >4.45 ptsExcellent** Uses correct grammar, spelling, and punctuation with no errors.<br> <br>**4.45 to >3.95 ptsGood** Contains a few (1 or 2) grammar, spelling, and punctuation errors.<br> <br>**3.95 to >3.45 ptsFair** Contains several (3 or 4) grammar, spelling, and punctuation errors.<br> <br>**3.45 to >0 ptsPoor** Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. | 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 to >4.45 ptsExcellent** Uses correct APA format with no errors.<br> <br>**4.45 to >3.95 ptsGood** Contains a few (1 or 2) APA format errors.<br> <br>**3.95 to >3.45 ptsFair** Contains several (3 or 4) APA format errors.<br> <br>**3.45 to >0 ptsPoor** Contains many (≥ 5) APA format errors. | 5 pts |
Charlene Baja is the Case study. Information needed to complete the assignment was provided in week two announcements. You will analyze a case study scenario to obtain information related to a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop a treatment and management plan. Please use the case study template.
**To prepare:**
· By Day 1 of this week, you will be choosing one of the two assigned case study scenarios provided.
· Review the Learning Resources for this week and pay close attention to the media program related to basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources.
· Carefully review the clinical guideline resources.
· Use the Case Study Template found in the Learning Resources to support the development of your assignment.
**Some questions to consider as you complete your SOAP NOTE for all Case Studies.**
·
**Subjective**: What details did the patient provide regarding her personal and medical history? What additional information is needed?
·
**Objective**: What observations did you make during the physical assessment? What additional assessment/observations are needed?
·
**Assessment**: What are your differential diagnoses? Provide a minimum of three possible differentials. List them from highest priority to lowest priority. What was your primary diagnosis and why?
·
**Plan**: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and , labs and diagnostic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
·
**Reflection notes**: What would you do differently in a similar patient evaluation?
**IMPORTANT**: For the
**Assessment** and
**Plan sections**, please make sure you don’t just list the differential and final diagnoses. I want to see your clinical reasoning/rationale based on the information you presented in subjective/objective information. This clinical reasoning should be supported by scholarly evidence. Scholarly evidence includes peer reviewed journal articles from the Walden library and/or current clinical guidelines from reputable sources within the last five years. This will address the "why" as stated above in the requirement
Remember the difference between a primary diagnosis versus a differential:
A Primary diagnosis-is the one diagnosis established after proper assessment/examination and testing has been completed.
Differential diagnosis is the process of developing a
list of the possible conditions that might produce a patient's symptoms and signs this is an important part of clinical reasoning. It enables appropriate testing to rule out possibilities and confirm a final (
primary) diagnosis.Practice and preparation decrease the incidence for errors.
Case Study week3
Case Study: Scenario 1
Charlene Baja is a 22-year-old G0 P0 L0 presents to the clinic today for burning and
discharge for 1 week. She states her boyfriend recently found out he was positive for
chlamydia. She denies any other partners besides him. Her medical history
is remarkable for anxiety and depression. Her surgical history is unremarkable. Her
social history includes social alcohol, but she denies tobacco and any recreational
drugs. She has no known drug allergies and takes a multivitamin and Srintec daily for
oral contraception. Her health history reveals that her mother is alive with breast
cancer in remission and hypothyroidism. Her paternal grandfather is alive with
prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes
type 2, and hyperlipidemia. Charlene has one brother with no medical history.
· Height 5’ 5” Weight 148 (BMI 24.6), BP 132/68 P 62
· HEENT: WNL
· Neck: lymph nodes grossly normal
· Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and
depth upon exam
· Breast: normal breast exam
· Abd: WNL
· VVBSU: WNL
· Cervix: firm, smooth, yellow watery discharge in large amount present
· Uterus: RV, mobile, non-tender
· Adnexa: WNL
## image1.jpeg
**## casestudywk3.docx**
Gynecologic Health
Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, diagnostic approaches, as well as the development of treatment plans.
For this Case Study Assignment, you will analyze a case study scenario to obtain information related to a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop treatment and management plans.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
[**WEEKLY RESOURCES**](https://waldenu.instructure.com/courses/185284/modules/items/7612942)
**To prepare:**
· Review the 4 case studies in this week’s Learning Resources. Select one of the cases to prepare your written assignment.
· Review the Learning Resources for this week and pay close attention to the media program related to the basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources.
· Carefully review the clinical guideline resources.
**Assignment Instructions:**
· Use the Case Study Template from the Learning Resources to complete the assignment. Your submission must include a brief case write-up, followed by the fully completed template, which must be integrated into the document rather than submitted separately.
· Include a title page, a case summary in your own words, the completed template, and a reference page formatted in APA style.
· Ensure your submission meets all criteria outlined in the template and rubric for completeness and accuracy.
By Day 7 of Week 3
**Submit** your case study assignment by
**Day 7 of Week 3**.
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the
**Turnitin Drafts** from the
**Start Here** area.
1. To submit your completed assignment, save your Assignment as
**Wk3Assgn_LastName_Firstinitial**
2. Then, click on
**Start Assignment** near the top of the page.
3. Next, click on
**Upload File** and select
**Submit Assignment** for review.
Rubric
**NRNP_6552_Week3_Case_Study_Assignment_Rubric**
| | | |
| — | — | — |
| NRNP_6552_Week3_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. | **30 to >26.7 ptsExcellent** The response provides clear, complete, and comprehensive descriptions of subjective and objective case data, appropriately outlining all diagnostic tests, clinical procedures and pharmacological interventions.<br> <br>**26.7 to >23.7 ptsGood** The response provides clear, complete partial descriptions of the components of the subjective and objective case data, appropriately outlining most of the diagnostic tests, clinical procedures and pharmacological interventions.<br> <br>**23.7 to >20.7 ptsFair** The response provides some components of the subjective and objective case data, but they are incomplete, vague or inaccurate, outlining some of the diagnostic tests, clinical procedures and pharmacological interventions.<br> <br>**20.7 to >0 ptsPoor** The response provides unclear or incomplete components of subjective and objective case data. The diagnostic tests, clinical procedures and pharmacological interventions are missing, incorrect, or inappropriately applied. | 30 pts |
| This criterion is linked to a Learning OutcomeIdentifies differential diagnoses related to case studies. | **30 to >26.76 ptsExcellent** The response contains at least 3 differential diagnoses relevant and applicable to the case.<br> <br>**26.76 to >23.7 ptsGood** The response contains at least 2 differential diagnoses relevant and applicable to the case.<br> <br>**23.7 to >20.7 ptsFair** The response contains at least 1 differential diagnosis relevant and applicable to the case.<br> <br>**20.7 to >0 ptsPoor** The response contains few or no differential diagnoses and/or diagnoses are not relevant and applicable to the case. | 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. | **30 to >26.76 ptsExcellent** Formulates a thorough treatment plan including explanations of appropriate diagnostic tests and treatment options. Fully incorporates syntheses representative of knowledge gained from the resources for the module and current credible sources, with no less than 75% of the treatment plan having exceptional depth and breadth. Supported by at least 3 current peer- reviewed, references or professional practice guidelines.<br> <br>**26.76 to >23.7 ptsGood** Formulates a partially complete treatment plan including partial explanations of appropriate diagnostic tests and treatment options. Somewhat incorporates syntheses representative of knowledge gained from the resources for the module and current credible sources with no less than 50% of the treatment plan having exceptional depth and breadth. Supported by at least 3 current peer- reviewed, references or professional practice guidelines.<br> <br>**23.7 to >20.7 ptsFair** Formulates a minimally complete treatment plan including incomplete or vague explanations of appropriate diagnostic tests and treatment options. Lacking in synthesis of knowledge gained from the resources for the module and current credible sources. Supported by at least 2 current peer- reviewed, references or professional practice guidelines.<br> <br>**20.7 to >0 ptsPoor** Formulates a treatment plan that contains incomplete explanations of appropriate diagnostic tests and treatment options and/ or explanations are missing. Lacks synthesis gained from the resources for the module and current credible sources. Supported by 1 or no current peer- reviewed, references or professional practice guidelines. | 30 pts |
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards:<br>Correct grammar, mechanics, and proper punctuation | **5 to >4.45 ptsExcellent** Uses correct grammar, spelling, and punctuation with no errors.<br> <br>**4.45 to >3.95 ptsGood** Contains a few (1 or 2) grammar, spelling, and punctuation errors.<br> <br>**3.95 to >3.45 ptsFair** Contains several (3 or 4) grammar, spelling, and punctuation errors.<br> <br>**3.45 to >0 ptsPoor** Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. | 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 to >4.45 ptsExcellent** Uses correct APA format with no errors.<br> <br>**4.45 to >3.95 ptsGood** Contains a few (1 or 2) APA format errors.<br> <br>**3.95 to >3.45 ptsFair** Contains several (3 or 4) APA format errors.<br> <br>**3.45 to >0 ptsPoor** Contains many (≥ 5) APA format errors. | 5 pts |
Charlene Baja is the Case study. Information needed to complete the assignment was provided in week two announcements. You will analyze a case study scenario to obtain information related to a comprehensive well-woman exam and determine differential diagnoses, diagnostics, and develop a treatment and management plan. Please use the case study template.
**To prepare:**
· By Day 1 of this week, you will be choosing one of the two assigned case study scenarios provided.
· Review the Learning Resources for this week and pay close attention to the media program related to basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources.
· Carefully review the clinical guideline resources.
· Use the Case Study Template found in the Learning Resources to support the development of your assignment.
**Some questions to consider as you complete your SOAP NOTE for all Case Studies.**
·
**Subjective**: What details did the patient provide regarding her personal and medical history? What additional information is needed?
·
**Objective**: What observations did you make during the physical assessment? What additional assessment/observations are needed?
·
**Assessment**: What are your differential diagnoses? Provide a minimum of three possible differentials. List them from highest priority to lowest priority. What was your primary diagnosis and why?
·
**Plan**: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and , labs and diagnostic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
·
**Reflection notes**: What would you do differently in a similar patient evaluation?
**IMPORTANT**: For the
**Assessment** and
**Plan sections**, please make sure you don’t just list the differential and final diagnoses. I want to see your clinical reasoning/rationale based on the information you presented in subjective/objective information. This clinical reasoning should be supported by scholarly evidence. Scholarly evidence includes peer reviewed journal articles from the Walden library and/or current clinical guidelines from reputable sources within the last five years. This will address the "why" as stated above in the requirement
Remember the difference between a primary diagnosis versus a differential:
A Primary diagnosis-is the one diagnosis established after proper assessment/examination and testing has been completed.
Differential diagnosis is the process of developing a
list of the possible conditions that might produce a patient's symptoms and signs this is an important part of clinical reasoning. It enables appropriate testing to rule out possibilities and confirm a final (
primary) diagnosis.Practice and preparation decrease the incidence for errors.
Case Study week3
Case Study: Scenario 1
Charlene Baja is a 22-year-old G0 P0 L0 presents to the clinic today for burning and
discharge for 1 week. She states her boyfriend recently found out he was positive for
chlamydia. She denies any other partners besides him. Her medical history
is remarkable for anxiety and depression. Her surgical history is unremarkable. Her
social history includes social alcohol, but she denies tobacco and any recreational
drugs. She has no known drug allergies and takes a multivitamin and Srintec daily for
oral contraception. Her health history reveals that her mother is alive with breast
cancer in remission and hypothyroidism. Her paternal grandfather is alive with
prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes
type 2, and hyperlipidemia. Charlene has one brother with no medical history.
· Height 5’ 5” Weight 148 (BMI 24.6), BP 132/68 P 62
· HEENT: WNL
· Neck: lymph nodes grossly normal
· Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and
depth upon exam
· Breast: normal breast exam
· Abd: WNL
· VVBSU: WNL
· Cervix: firm, smooth, yellow watery discharge in large amount present
· Uterus: RV, mobile, non-tender
· Adnexa: WNL
## image1.jpeg