EMEDLEY CASE STUDY #6.docx - Running head CASE STUDY#6 EMEDLEY CASE STUDY#6 Lisa Chhin BSN RN PHN Charles R Drew University of Medicine and Science

EMEDLEY CASE STUDY #6.docx - Running head CASE STUDY#6...

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Running head: CASE STUDY #6 EMEDLEY CASE STUDY #6 Lisa Chhin BSN, RN, PHN Charles R. Drew University of Medicine and Science Mervyn M. Dymally School of Nursing NUR 632 Primary Care of Women and Children March 14, 2019
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Running head: CASE STUDY #6 EMEDLEY CASE STUDY#6 (6175997) CHIEF COMPLAINT: abnormal bleeding HISTORY OF PRESENT ILLNESS: Patient is a 57-year-old female c/o abnormal bleeding. Patient has been in menopause for over 10 years. Patient has been complaining of pelvic pain with bleeding for 4 months ALLERGIES: No known drug and food allergies; Immunization: immunization up to date PAST MEDICAL HISTORY: no past medical history FAMILY HISTORY: unknown SOCIAL HISTORY: Patient denies drinking, smoking, and illicit drug use. SURGICAL HISTORY: No surgical history REVIEW OF SYSTEMS: CONSTITUTIONAL: denies chills, (-) weight gain, (-) decrease in appetite SKIN: (-) rash, (-) dry skin, (-) lesions, (-) brittle hair HEENT: (-) HA, (-) dizziness, (-) lightheadedness or vertigo, (-) visual changes, (-) hearing loss, (-) sinus tenderness with patent nasal passage, (-) throat pain CARVIOVASCULAR: (-) complaint of chest pain, palpitation or edema to extremities RESPIRATORY: (-) cough, (-) respiratory distress, (-) no adventitious breath sounds GASTROINTESTINAL: (-) appetite change, (-) constipation, (-) nausea or vomiting GENITOURINARY: (+) vaginal bleeding, (+) pelvic tenderness, (-) discharge, (-) dysuria NEUROLOGIC: (-) speech or coordination difficulties, (-) fatigue, (-) difficulty concentrating, (-) numbness, tingling, loss of concentration
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Running head: CASE STUDY #6 MUSCULOSKELETAL: (-) muscle pain, aches, or weakness, HEMATOLOGIC: (-) anemia, (-) easy bruisability, (-) bleeding disorder PSYCHIATRIC:
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  • Spring '18
  • vaginal bleeding, Endometrium, Adenomyosis, uterine sarcoma

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