Missed Period Case Study Solved
Missed Period Case Study Solved
Missed Period Case Study Solved
Case Study: Missed Period
Juanita Morales is a 47-year-old G5P5006, Hispanic female who presents to the office complaining of lower abdominal cramping, and urinary leakage for past day. She states the abdominal cramping, suprapubic, started several hours ago, is sharp, intermittent, and getting more frequent and painful. She tried Motrin but states it did not help. She had a UTI years ago and it was like this, except the incontinence. She has been more tired for the past several months. She relates she stopped getting her period about 8-12 months ago, and relates her menopause was easy. She relates no medical or surgical history. She has no known drug allergies and takes no medications. Social history is negative for alcohol, tobacco, and recreational drugs. Her last exam was several years ago.
Vital signs: temperature 99.1, BP 140/ 82, pulse 88, respirations 12. Height is 5’ and weight 235 lbs. (BMI 45.89). A clean catch urine was obtained, and the urine dipstick showed SG 1.010, trace blood, neg nitrates, neg leukocytes, negative glucose, 3+ protein. She thinks that maybe she had some vaginal spotting several days ago, but nothing since.
Pt relates that she has had some constipation, and increased gas for past several months. She was using NFP for contraception prior to her stopping her period. No other urinary symptoms reported.
Based on the above case study, post the following:
· POST A Focused SOAP NOTE only and describe your case study.
· Provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
· Define what you believe is the most important diagnosis. Be sure to include the priority in conducting your assessment.
· Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.
· Also, share with your colleagues your experiences as well as what you learned from these experiences.