Case Study Discussion Assignment Paper

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, and diagnostic approaches, as well as to the development of treatment plans.

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For this Case Study Discussion, you will once again review 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 Case Study Discussion Assignment Paper.

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To prepare:

  • By Day 1 of this week, you will be assigned to a specific case study scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
  • Review the Learning Resources for this week and specifically review the clinical guideline resources specific to your assigned case study.
  • Use the Focused SOAP Note Template found in the Learning Resources to support your Discussion. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your FOCUSED SOAP note. This information will help you develop your differential diagnosis and additional questions

By Day 3

Please POST your FOCUSED SOAP NOTE and post your primary diagnosis. Include the additional questions you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)

Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of diagnostic tests you would recommend and explain your reasoning. Use your Learning Resources and/or evidence from the literature to support your position.

 CASE STUDY

Case Study 2

Case Study: STI Investigation

Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full-time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / EtOH only on weekends, 6-8 hard liquor/ daily, and marijuana smoking. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has some cramping during her menses for which she takes otc Pamprin. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies. Susan’s vital signs are taken and were temperature 97.8, pulse 68, BP 112/64, height 5’6” and weight 118 lbs. (which was the same as last year). BMI 19.04 Case Study Discussion Assignment Paper  

 

  • HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened.
  • Lung:clear to auscultation
  • CV: regular sinus rhythms without murmur or gallop
  • Abd: soft, non-tender, liver normal,
  • Breasts:fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.
  • VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
  • Cervix: friable, some petechia no cervical motion tenderness.
  • Uterus: mid mobile, non-tender
  • Adnexa: without masses or tenderness Case Study Discussion Assignment Paper
  • Perineum:wnl
  • Rectum:wnl
  • Extremities: full rom, skin clear, no edema, reflexes 1+.
  • Neurological: CN II-12 grossly intact.

INSTRUCTIONS

You will use a case study to analyze information obtained from well-woman examinations. You also will consider and propose treatment plans for diagnoses.  The earning objectives for this week include:

  • Analyze pertinent patient information obtained from a comprehensive well-woman exam
  • Formulate differential diagnoses
  • Recommend diagnostics to support differential diagnoses
  • Develop treatment and management plans
  • Develop additional questions to support patient assessments

Focused SOAP Note: STI Investigation

Patient Information:

Initials: S. L. Age: 24 Sex: Female Race: Caucasian

S

CC: post-coital bleeding and a sore throat.

HPI: SL is a 24-year-old Caucasian woman who has come to the facility for routine care and treatment. She claims that she has been experiencing post-coital bleeding for six weeks and that she has had throat soreness for the previous three weeks. Furthermore, she claims to have had a fever for about one to two days that disappeared with Tylenol, which she assumed was due to allergies at first. A past medical history is not mentioned by the patient Case Study Discussion Assignment Paper.

Current Medications: Tylenol and Pamprin

Allergies: NKDA

PMHx: Denies medical history

Surgical hx: None

 Family hx: Non-contributary

Social hx: She is employed as an admin assistant at a company. She has been smoking 12 packs per day for the last ten years, drinking alcohol on weekends (six to eight strong liquors a day), and using cannabis. She jogs three to four times each week, sometimes applies sunscreen, and usually uses a seatbelt.

Reproductive hx: Her menstrual cycle began when she was thirteen years old. She has menstrual periods every 28-32 days that last 4-6 days and uses three tampons per day. For menstruation cramping, she takes Pamprin.

ROS:

General: Recently had fever that lasted for 1-2 days. No recent weight changes.

HEENT: Denies vision problems, hearing problems, and runny nose. Reports sore throat that has lasted for three weeks.

Cardiovascular: Denies palpitations, chest pressure and pain.

Respiratory: Denies shortness of breath, cough and breathing problems.

Gastrointestinal: Denies constipation, diarrhea, vomiting, and nausea.

Genitourinary: Denies dysuria, polyuria and hematuria.

Neurological: Denies headache, ataxia, and dizziness. No tingling or numbness.

Musculoskeletal: Denies joint stiffness and pain, back pain, and muscle pain. Denies history of fractures and trauma.

Hematologic: Denies bleeding, easy bruising and history of anemia.

Lymphatics: Denies history of splenectomy. Denies enlarged nodes.

Psychiatric: No history of anxiety and depression Case Study Discussion Assignment Paper.

Endocrinologic: Denies heat and cold intolerance, and night sweats. Denies polydipsia and polyuria.

Reproductive: Reports postcoital bleeding that has lasted for 6 weeks

O

Physical exam:

Vital signs: T 97.8, P- 68, BP 112/64, HT- 5’6” and WT-118 lbs. BMI 19.04

HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened.

Lung: clear to auscultation.

CV: regular sinus rhythms without murmur or gallop.

Abdomen: soft, non-tender, liver normal.

Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.

VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted

Cervix: friable, some petechia no cervical motion tenderness.

Uterus: mid mobile, non-tender

Adnexa: without masses or tenderness

Perineum: Intact no lesions or warts

Rectum: Intact no lesions or bleeding

Neurological: Cranial nerves 2-12 intact. The sensation of pain, touch, and proprioception is intact.

Extremities: Full Range of motion, skin clear, no edema, reflexes 1+.

A

Questions

Have you ever been diagnosed with a sexually transmitted infection (STI)?

Are you taking any precautions against sexually transmitted infections including HIV?

Do you have any vaginal dryness?

When it comes to vaginal discharge, is there a distinct odor?

Have you been tested for sexually transmitted infections or HIV?

Do you have any back pain, abdominal discomfort, or pelvic pain?

How many sexual partners have you had in the previous 60 days?

What kinds of sexual acts do you engage in?

Do you experience burning or itching in your vaginal area?

Has your vaginal region, or any other part of your body, been affected by sores?

These are relevant questions to raise since condoms are the primary protective technique that provides efficient safety from sexually transmitted diseases. The usage of a condom along with any other form of birth control should be recommended to patients (Tharpe et al., 2017).

Diagnostic Testing

It is possible to detect very minute quantities of RNA or DNA in test specimens using the Nucleic-Acid Amplification Test (NAAT). A rectal, vaginal, or oral swab can be used for this procedure. NAAT may be performed on urine samples.  There are a range of sexually transmitted diseases that may be detected with this method, such as trichomoniasis, chlamydia, and gonorrhea (CDC, 2020)Case Study Discussion Assignment Paper.

In this patient, a pH test is required since typical vaginal fluids have a pH of below 4.5. The presence of trichomoniasis is indicated by a pH greater than 4.5.

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Differential Diagnosis

Trichomoniasis – It is caused by a parasite and is one of the most prevalent sexually transmitted infections (STIs). There are several symptoms of trichomoniasis, including a foul-smelling vaginal secretions and genital itchiness. The secretion might be whitish, greenish, grayish, or yellowish in color, and it can be frothy at times (Dains et al., 2016).

Trichomoniasis is treated with either Tinidazole 2 gm in a single dosage or Tinidazole Metronidazole 2 gm in a single dosage (Schuiling & Likis, 2017). Consuming alcohol within one day of taking Metronidazole or within 3 days of using Tinidazole must be avoided since it might induce extreme vomiting and nausea. Partners in sexual activity should also be given treatment, and patient should refrain from having sexual relations until her sexual partners have been treated successfully and are no longer exhibiting symptoms (Schuiling & Likis, 2017) Case Study Discussion Assignment Paper.

Chlamydia– This is the most frequent illness that is spread via sexual contact. A bacteria called Chlamydia trachomatis is to blame, and it’s normally asymptomatic when one has it. It may take many weeks for symptoms to manifest themselves following infection. Purulent cervical discharge, post-coital bleeding, vaginal spotting, and vaginal secretion, frequent urination, lower stomach discomfort, and painful urination are some of the symptoms that may be seen with this condition. When chlamydia is present, the symptoms might be confused with those of a UTI (Schuiling & Likis, 2017).

For chlamydia, Doxycycline 100mg taken twice per day for one week or Azithromycin 1 gm given as a single dosage is the suggested course of treatment. Clients must be reminded that they should be rescreened three months following therapeutic interventions to see if they have acquired the disease again (Schuiling & Likis, 2017).

Pelvic Inflammatory Disease (PID) – This is a female upper genital tract infection, which includes the ovaries, uterus, and oviducts. It is usually generated by gonorrhea and chlamydia. Postcoital bleeding and excessive vaginal secretions are common symptoms in females with PID, as are stomach discomfort and fever (Dains, Baumann, & Scheibel, 2016).

The suggested therapeutic intervention for PID is Cefoxitin 2 g IV every 6 hours plus Doxycycline 100 mg orally or IV every 12 hours, Cefotetan 2 g IV every 12 hours hours plus Doxycycline 100 mg orally or IV every 12 hours, or Ceftriaxone 1 g IV every 24 hours plus Doxycycline 100 mg orally or IV every 12 hours plus Metronidazole 500 mg orally or IV every 12 hours. Individuals with this condition should be urged to refrain from sexual intercourse until their treatment has ended, their manifestations have disappeared, and their sex partners have recovered (Schuiling & Likis, 2017)Case Study Discussion Assignment Paper.

Decision Tree: Complex Regional Pain Disorder in a 43 Year-Old Caucasian Male with Hip Pain

This is the case of a 43 year-old Caucasian male who presents to the clinic for psychiatric evaluation and treatment by a psychiatric-mental health nurse practitioner (PMHNP). His chief complaint is that of recalcitrant unrelenting pain that has him using crutches for mobility. He reveals at the beginning of the interview that the primary care physician sent him for psychiatric evaluation because he suspects that the pain is of psychological origin. As such, he claims the physician thinks he just wants to get a prescription of strong opioid analgesics to get high on. Subjectively, the patient reports that the pain symptom started 7 years ago following a fall at work. He has since then had a myriad of diagnostic tests done including X-rays and MRIs but with little progress. A tear of the cartilage around his right hip was noted at one time but surgeons thought he was too young for a total hip replacement and that it would heal by itself. Later on, a neurologist diagnosed him with complex regional pain syndrome (CRPS) also known as reflex sympathetic dystrophy or RSD. Before being incapacitated by the unrelenting pain, he had been a machinist and was engaged. However, his fiancée left him as she could not keep up with his constant pain and incapacity. While at the clinic, he suffers what appears to be cramping of the right leg with stiffness and cyanosis for about a minute or so. He reveals that his PCP has been giving him hydrocodone which is an addictive opioid analgesic. He however says that he only takes it occasionally and sparingly out of fear of the side effects of drowsiness and constipation. The mental status examination reveals that this 43 year-old male is alert and oriented to person, place, time, and event. He is appropriately dressed with speech that is coherent, spontaneous, clear, and goal-directed. Self-reported mood is euthymic and congruent with the affect. He denies delusions or hallucinations as well as having a paranoid thought process. Judgment and insight are grossly intact and there is no suicidal or homicidal ideation. The primary diagnosis made is that of complex regional pain disorder (reflex sympathetic dystrophy). According to Zanotti et al. (2017), complex regional pain syndrome (CRPS) or RDS constitutes relentless atypical pain that is chronic. The pain is principally neuropathic (Birklein & Dimova, 2017) but may also result from orthopedic procedures. Etiologically, this patent’s CRPS is definitely neuropathic. The purpose of this paper is to outline three therapeutic decisions taken by the PMHNP in deciding the appropriate pharmacotherapy for this patient Case Study Discussion Assignment Paper.

Decision Point Number 1

At this first decision point, the PMHNP was to make the first of the three decisions. Three pharmacotherapeutic options are presented as follows:

  1. Milnacipran (Savella) 12.5 mg by mouth once on day 1; followed by 12.5 mg BID on the second and third days; followed by 25 mg BID on the fourth to the seventh day; then 50 mg BID thereafter. OR
  2. Amitriptyline 25 mg orally QHS titrated upward every week by 25 mg up to a maximum dose of 200 mg per day. OR
  • Neurontin 300 mg orally at bedtime increased weekly by 300 mg up to a maximum of 2,400 mg.

After considering the three options above, the first option was taken. The decision was therefore made to:

  • Start milnacipran (Savella) 12.5 mg by mouth once on day 1; followed by 12.5 mg BID on the second and third days; followed by 25 mg BID on the fourth to the seventh day; then 50 mg BID thereafter (Stahl, 2017).

The reason for this choice of pharmacotherapy is that milnacipran is FDA-approved for the treatment of fibromyalgia which is almost clinically identical to CRPS (Stahl, 2017). It is a serotonin and norepinephrine reuptake inhibitor (SNRI) that blocks both serotonin and norepinephrine. Because it is evidence-based treatment for fibromyalgia with ample scholarly evidence backing its efficacy, it is clinically extrapolated that it would be beneficial in reducing the pain of CRPS in the same manner. Lee et al. (2019) have stated that CRPS and fibromyalgia have many common clinical features. They opine that the two cause severe pain and seem to have the same mechanism of manifestation, including through dysfunction of the sympathetic division of the autonomic nervous system Case Study Discussion Assignment Paper.

The reason why the other two pharmacotherapeutic options were not taken is because they would have not made a better difference clinically compared to milnacipran (Savella). Studies have shown that both CRPS and fibromyalgia do not really have any effective pharmacotherapeutic treatment (Vincent et al., 2013). Therefore, the other two options would no match Savella which is at least effective in the clinically identical fibromyalgia. What was expected in making the above choice was that the patient would have a gradual but sustained therapeutic response with a reduction in pain and better mobility without crutches. The most important ethical consideration made above was to base the clinical decision on proven efficacy of Savella in fibromyalgia hence giving the patient the opportunity of beneficence (Haswell, 2019).

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Decision Point Number 2

After four weeks on the milnacipran (Savella), the patient returned for follow-up and review in the clinic. He was definitely showing improvement as he had no crutches this time but only limping a bit. He stated that he could move around a lot more on his own and that even though the pain was more in the morning it got better as the day progressed. This time he rated his pain score better at 4/10 denoting improvement. He however complained if excessive diaphoresis for no clear reason, insomnia, and nausea. The three options to be chosen from this time were as follows: Case Study Discussion Assignment Paper

  1. Continue with milnacipran (Savella) but reduce the dose to 25 mg orally BID. OR
  2. Discontinue milnacipran and commence pregabalin (Lyrica) 50 mg orally twice a day. OR
  • Discontinue milnacipran and commence sertraline (Zoloft) 50 mg every day.

After consideration of the patient’s status report after the initial four weeks of therapy, the decision that was taken by the PMHNP at this second decision point was to:

  • Continue with milnacipran (Savella) but reduce the dose to 25 mg orally BID

The rationale for settling for this decision was that the patient was definitely showing a clear therapeutic response to the Savella. He had stopped using his crutches and could move around by himself though limping. His pain had also significantly reduced such that he was rating it at 4/10 on the pain scale. This therapeutic response alone (even though not yet 100%) was enough to inform the clinical decision of continuing with the milnacipran (Savella) in this patient. However, he also clearly had been experiencing some side effects of the medication. It is for this reason that the dose was titrated downwards to 25 mg BID instead of 50 mg BID Case Study Discussion Assignment Paper.

What was hoped to be achieved by this decision was to sustain the therapeutic response but reduce the side effects. The reason why the other two options were not selected is that they would not have made any clinical difference at this point. Also, the patient was already showing a therapeutic response to the milnacipran. The ethical consideration in this case was a delicate balance between beneficence and nonmaleficence (Haswell, 2019). Keeping the patient on the milnacipran would be beneficial to them as they were already showing some improvements by using it. However, he also had side effects and to prevent further harm to him, the dose had to be adjusted downward.

Decision Point Number 3

After another four weeks the patient returns for another evaluation and review. This time he is back to using his crutches and states that the pain has now gone back upwards to about 7/10. He is not feeling as better as he did the previous month when he came for the second visit. He is no sleeping at night but the pain wakes him up. Whereas he had palpitations last time, he denies having them this time round. From this assessment, it is clear that the milnacipran dose of 25 mg BID is not sufficient to sustain the therapeutic response that had been seen within the first four weeks. This is why the pain score has increased and the patient is back to using crutches. The three options presented in this third and last decision point were as follows: Case Study Discussion Assignment Paper

  1. To change milnacipran (Savella) to 25 mg orally in the morning and 50 mg orally at bedtime. OR
  2. To discontinue milnacipran and commence tramadol 50 mg by mouth every 6 hours; to be increased to 100 mg orally every 6 hours if pain not well controlled. OR
  • To reduce milnacipran to 12.5 mg orally BID and start citalopram (Celexa) 10 mg orally every day.

After careful consideration of all factors, the decision taken in this third and last decision point was to:

  • Change milnacipran (Savella) to 25 mg orally in the morning and 50 mg orally at bedtime.

The reason for this choice or decision was that there was evidence that the patient was responding to treatment with milnacipran (Savella) used to treat the pain of fibromyalgia (Vincent et al., 2013). All that was needed therefore was to get the right mix of dosing for the medication to achieve a balance between side effects and therapeutic response. Giving a lower dose in the morning and a higher one at bedtime would do this. What was hoped with this decision was to achieve and sustain a therapeutic response and to stop side effects. The reason why the other two options were not selected was that the addition of a different medication was not going to help as per the current evidence-based practice (EBP) tenets. Ethically, it made sense to give a smaller dose in the morning and a higher one in the evening so that the patient may not suffer side effects (nonmaleficence) but get the full benefits including pain relief (beneficence) Case Study Discussion Assignment Paper.

Brief Description

Complex regional pain syndrome (CRPS) or reflex sympathetic dystrophy (RSD) is a condition of neuropathic pain that is chronic but that does not really have an organic cause. The pain is characteristically atypical and persistent (Zanotti et al., 2017; Birklein & Dimova, 2017). The decision tree steps applied in the case of this 43 year-old male with hip pain comprised of commencing milnacipran (Savella) at decision point 1, continuing with the same medication but lowering the dose (decision point 2), and changing the milnacipran dosage and frequency to 25 mg in the morning and 50 mg at bedtime. It is thought that the pathophysiology of CRPS stems from a dysfunction of the sympathetic division of the autonomic nervous system. Being a serotonin norepinephrine reuptake inhibitor (SNRI), milnacipran causes accumulation of both serotonin and norepinephrine at the synaptic cleft. This results in some form of potentiation that corrects the sympathetic dysfunction. This pharmacodynamic impact on the pathophysiology would inform my suggestion of treatment plans in that I will not change the medication midway in therapy. For example, that is what has been done in this case. The only thing that has been done is to titrate the dose and frequency against the therapeutic response of the patient Case Study Discussion Assignment Paper.

References

Birklein, F., & Dimova, V. (2017). Complex regional pain syndrome – up-to-date. Pain Reports, 2(6), e624. https://doi.org/10.1097/PR9.0000000000000624

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Lee, J-Y., Choi, S-H., Park, K-S., Choi, Y.B., Jung, H.K., Lee, D., Jang, J.H., Moon, J.Y., & Kang, D-H. (2019). Comparison of complex regional pain syndrome and fibromyalgia: Differences in beta and gamma bands on quantitative electroencephalography. Medicine (Baltimore), 98(7), e14452. Case Study Discussion Assignment Paper https://doi.org/10.1097/MD.0000000000014452

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.

Vincent, A., Benzo, R.P., Whipple, M.O., McAllister, S.J., Erwin, P.J., & Saligan, L.N. (2013). Beyond pain in fibromyalgia: Insights into the symptom of fatigue. Arthritis Research and Therapy, 15(6), 221. http://dx.doi.org/10.1186/ar4395

Zanotti, G., Slullitel, P.A., Comba, F.M., Buttaro, M.A., & Piccaluga, F. (2017). Three cases of type-1 complex regional pain syndrome after elective total hip replacement. SICOT-J, 3(52). https://doi.org/10.1051/sicotj/2017038

References

Center for Disease Control (CDC). (2020). Gonorrhea Treatment and Care. https://www.cdc.gov/std/gonorrhea/treatment.htm

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby. https://evolve.elsevier.com/cs/product/9780323554961?role=student

Schuiling, K.D & Likis, F.E. (2017). Women’s Gynecologic Health (3rd ed.). Jones and Barlett Publishers. https://www.academia.edu/42888634/WOMENS_GYNECOLOGIC_HEALTH_THIRD_EDITION

Tharpe, N. L., Farley, C. L., Jordan, R. G. (2017). Clinical Practice Guidelines for Midwifery & Women’s Health (5th ed.). Jones and Bartlett Publishers Case Study Discussion Assignment Paper