Grace is a 32 year old single Chinese Female who presents with a…
Grace is a 32 year old single Chinese Female who presents with a… Grace is a 32 year old single Chinese Female who presents with a non-tender lump under her left arm. She noted it 2 weeks ago during SBE. She also reports fatigue, scratchy throat, low grade fever and occasional night sweats. She has been off of her BCP for 1 year. Her last GYN exam was 2 years ago. She was sexually active until 4 weeks ago, when she did have unprotected vaginal intercourse. Grace is an international computer analyst. She usually travels to Singapore. Her latest trip was 4 weeks ago; she works 14 hours a day. No allergies; no medications; no chronic health problems. No surgeries. One glass of wine per day; 10-12 cups of coffee per day. ROS: OB/GYN: menses @ age 13; g0 p0 a0; has never had a mammogram hx of genital herpes in 1998 with outbreaks 1-2 times/year; no Acyclovir needed in the past 6 months; she currently denies dysuria, frequency, vaginal d/c or painful intercourse PE:VS: 98.4-68-18 110/60 5’6″ 130#General: Pleasant female; NADHEENT: normocephalic; PERRLA; no evidence of retinopathy; throat clear; tm’s unremarkableNeck: bilateral posterior [multiple] palpable cervical lymph nodes; 1-2 cm. in size; no thyromegaly Lungs: CTA a/pHeart: RRR; no clubbing, cyanosis or edema; no m/g/rBreast: left axillary node 3 cm.; nontender; mobile no other lymphadenopathy; no breast mass, no discharge no nippleinversionAbdomen: spleen 2 cm. below left costal margin; no hepatomegaly; BS X 4 quadrants; bilateral inguinal lymph nodes, enlarged 2 cm. s:AssessmentMedical Diagnoses Differential Diagnoses Nursing Diagnosis/Health Maintenance or Social issue Initial Treatment Plan Diagnostics/Laboratories [List any additional diagnostics or lab tests you believe are needed] Rxs [Identify initial prescriptions, referrals, nonpharmacological medical treatments needed] __Nursing Interventions / Education [cite follow-up and specific health promotion and education needs] Health Science Science Nursing NURS 6090 Share EmailCopy link Comments (0)
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