Nursing Question
if you see this time all her diagnosis are managed and controled and I wrote front each one how controlled each disease the primary is PCOS and the rest are diffrential … so read History of Present Illness and Medical History ro see how she controlled and make a connections
History of Present Illness
Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.
Medical History
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.
Diagnostic Test/Labs:
1. Complete Blood Count (CBC):
2. Blood Chemistry Panel: ex A1C
3. Urinalysis:
Primary Diagnosis
1. Polycystic Ovarian Syndrome (PCOS) the patient started taking the prescribed medication Yaz four months ago, and she has been successfully managing her PCOS ever since
Deferential Diagnoses
2. Asthma Three months ago, she experienced an asthma attack, but she was able to treat it by using her albuterol inhaler
3. Diabetes Mellites Type II: metformin, a drug that is frequently prescribed for diabetes, five months ago, changing her lifestyle in addition to taking medication. These changes include dietary restrictions and regular exercis
4. Hypertension : her blood pressure normalized when she started dieting and exercising.
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