Gynecologic Health Case Study: Charlene Baja

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

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

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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 ptsExcellentThe response provides clear, complete, and comprehensive descriptions of subjective and objective case data, appropriately outlining all diagnostic tests, clinical procedures and pharmacological interventions. 26.7 to >23.7 ptsGoodThe 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. 23.7 to >20.7 ptsFairThe 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. 20.7 to >0 ptsPoorThe 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 ptsExcellentThe response contains at least 3 differential diagnoses relevant and applicable to the case. 26.76 to >23.7 ptsGoodThe response contains at least 2 differential diagnoses relevant and applicable to the case. 23.7 to >20.7 ptsFairThe response contains at least 1 differential diagnosis relevant and applicable to the case. 20.7 to >0 ptsPoorThe 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 ptsExcellentFormulates 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. 26.76 to >23.7 ptsGoodFormulates 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. 23.7 to >20.7 ptsFairFormulates 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. 20.7 to >0 ptsPoorFormulates 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: Correct grammar, mechanics, and proper punctuation	5 to >4.45 ptsExcellentUses correct grammar, spelling, and punctuation with no errors. 4.45 to >3.95 ptsGoodContains a few (1 or 2) grammar, spelling, and punctuation errors. 3.95 to >3.45 ptsFairContains several (3 or 4) grammar, spelling, and punctuation errors. 3.45 to >0 ptsPoorContains 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 ptsExcellentUses correct APA format with no errors. 4.45 to >3.95 ptsGoodContains a few (1 or 2) APA format errors. 3.95 to >3.45 ptsFairContains several (3 or 4) APA format errors. 3.45 to >0 ptsPoorContains 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

Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!

Step 1: Read and Understand the Case

You are working with Charlene Baja, a 22-year-old presenting with burning and discharge for one week.

• Her boyfriend tested positive for chlamydia.

• She has no surgical history, uses oral contraceptives, and has a family history of cancer, diabetes, and hypertension.

• Exam reveals yellow watery cervical discharge, otherwise normal findings.

Step 2: Structure Your Paper Using the Template

Your assignment must include:

1. Title Page (APA format)

2. Case Summary – Write the case in your own words (do not copy-paste).

3. SOAP Note Template (provided in Learning Resources)

4. Reference Page in APA

Step 3: Fill Out Each Section of the SOAP Note

• Subjective:

  • Presenting symptoms (burning, discharge).

  • History (sexual partner with chlamydia, OCP use, mental health, family history).

  • Medications, allergies, lifestyle.

  • Add what further info you’d ask: onset of symptoms, pain, menstrual history, STI history, condom use.

• Objective:

  • Physical exam results (normal except cervix: firm, smooth, yellow watery discharge).

  • Vital signs.

  • Additional tests to order: NAAT for C. trachomatis and N. gonorrhoeae, wet prep, pregnancy test, HIV and syphilis screening.

• Assessment:

  • Differential diagnoses (at least 3):

    1. Chlamydia cervicitis (most likely) – supported by discharge, partner history.

    2. Gonorrhea – can present with similar symptoms.

    3. Trichomoniasis – vaginal discharge but usually frothy/greenish, needs to be ruled out.

  • Primary Diagnosis: Chlamydia infection.

• Plan:

  • Diagnostics: NAAT, HIV/syphilis screen, pregnancy test.

  • Treatment:

    • CDC guidelines: Doxycycline 100 mg orally twice daily for 7 days (first-line).

    • Partner treatment (expedited partner therapy).

    • Abstain from intercourse until 7 days post-treatment.

  • Management: Education on STI prevention, safe sex, follow-up testing in 3 months.

  • Alternative therapies: Azithromycin (if compliance is a concern or pregnancy suspected).

  • Referrals: Counseling if anxiety/depression worsens.

• Reflection:

  • Note what you learned about applying differential reasoning.

  • Explain how this practice strengthens clinical judgment for future patient care.

Step 4: APA Formatting and Scholarly Sources

• Use current guidelines (CDC STI Treatment Guidelines, 2021).

• Support reasoning with at least 3 peer-reviewed references (last 5 years).

• Ensure all in-text citations match the reference list.

Step 5: Resources for Support

• CDC 2021 STI Treatment Guidelines: Chlamydia

• Walden University Library (for peer-reviewed sources)

• Purdue OWL: APA Formatting

 

 

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