Question

Write an 8- to 10-page comprehensive assessment that addresses the following: Age, race and ethnicity, and partner status of the patient Current health status, including chief concern or complaint of the patient Contraception method (if any) Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem) Review of systems Physical exam Labs, tests, and other diagnostics Differential diagnoses Management plan, including diagnosis, treatment, patient education, and follow-up care

Answer 1

Answer :

Comprehensive assessment of contraceptive using client :

Name : Mrs. Rathnamma

Age : 28yrs

Race and ethnicity : Indian, Hindu, block woman

Husband name : Mr. Venkatesh

Patient current health status :

Chief complaints : Mrs. Rathnamma using intra uterine contraceptive device that is copper T 380 A, since three months, now she is having a heavy menstrual flow and abdominal pain and severe cramps, fever , Peri orbital edema,, weakness, since five days.

Medical history : she suffered from dengue fever 5 months back and used medications and cured, it is past medical history.

Now she is suffering from fever and abdominal pain so she took paracetamol tablet and meftalspas tablet. For bleeding nothing she was talken.

Family medical history : her father is suffering from diabetes mellitus and anemia.

Gynecologic history : she is having 45 days cycle history.

Obstetrical history : her GPLA score is

gravida1

Para 1

Live 1

Abortion 0.

Now she is having 1year 5 months old child, that's way she is using iucd.

Personal social history : she is having pakka house, adequate water supply, she studied 12 th standard, at present she is house wife.

She communicates well with neighbors.

Physical examination :

On this she is coherent and consciousness, responding well for questions, moderate body built, looks dull and pale and dried lips, pale nails.

All systems are normal except reproductive and hemotological systems.

Lab tests :

Hemoglobin levels are 7 gm/ dl.

Platelets are 1 lakh cc3

Wbc count is 12000.

CRP (C reactive protein ) high

Differential diagnosis :

Is we can suspect dengue hemorrhagic fever ,because she is having low platelets and periorbitol edema and fever.

And sepsis or infection due to asceptic techniques followed after iucd insertion. Because wbc count are high and CRP also high.

Management and treatment :

Inj : tranexamic acid for bleeding or ethamsulate.

Inj. Dicyclomine for abdominal pain and cramps.

Inj : paracetamol for fever.

Tab : rantac or pantap to reduce acidity.

Tab : multivitamin to increase blood

Arrange for blood transfusion.

Antibiotic should be keep after doing blood culture and sensitivity, after knowing which micro organism is causing infection whether it is gram positive or gram negative.

Because unrelated antibiotics using leads to resistance of client to them.

Education :

* educate about to take plenty of oral fluids.

* educate to take vitamin c rich diet to absorb Iren, to increase hemoglobin.

* encourage to take nutritious diet.

* education about iron rich diet like liandates and green leafy vegetables etc.

* maintain personal hygiene.

* use cleanliness on personal parts.

Follow up care :

* educate client to use treatment correctly.

* observe for any danger signs like still heavy bleeding and shock.

* come and consult doctor if not reducing the symptoms by using treatment also.