Develop a tentative problem list with appropriate differential diagnoses

Case Study -2016

Directions:  The focus of this case study is the primary care of this client.  It may be important to discuss pathophysiologic or pharmacotherapeutics processes or information, but the focus should be on the assessment (history and physical) and the plan of care (problem identification and plan). Your paper should demonstrate your understanding of the diagnostic process utilized by advance practice nurses.  Please include a reference list in APA format.

RS is a 37 year-old Hispanic female who presents with the complaint of headaches.  This is the first office visit since coming to the US one year ago. She notes a change in the usual headaches that she had been having since starting schools this fall.

She has had “bad headaches” that are located at the back of the neck and feel like a tight band around the head. Recently she has had unilateral headaches that are rated as 7, on a scale of 1-10. These seem to be worse before her period and often are so bad that she must go to sleep to get rid of it. In taking her history you find out that three months ago she was started on oral contraceptives. Following this line of questioning, you also find out that she has had 3 sexual partners in the last 3 months and now notes the presence of vaginal discharge that has a foul odor.

Vital Signs: Afebrile, BP 148/94, Pulse 92, Resp. 14

While reviewing the chart, you note that this patient has not been seen in your office for over 1 year.

1. Discuss what further historical data is needed. (20 points)
2. Develop a tentative problem list with appropriate differential diagnoses. (20 points)
3. For each differential diagnosis, discuss the historical and physical exam finding that would support this diagnosis. Give rational. (20 points)
4. From this tentative list chose the most likely diagnosis for each problem (Hint: Consider psychosocial/cultural implications for this patient) and develop an appropriate plan of care. Give rational for interventions. (30 points)
5. Pick one of the non-pharmacologic interventions that you listed for the most likely diagnosis (or the primary problem for this visit) and write up an overview of the intervention from an evidence-based perspective. (5 points)