History of Present Illness (HPI): Maxine, a 31-year-old G0, is an established patient of your practice and
presents today for a routine well woman exam. She was married 4 months ago after a short courtship
with a family friend. She denies any complaints, however, you notice she is more withdrawn that usual
and is not making eye contact with you. When asked about her menstrual cycle, she states her menses
have been irregular over the past 3 months, skipping one month and bleeding twice the next month.
Last period was 2 weeks ago and was a very heavy flow that, causing her to change tampons every hour
on the first 2 days. She is not using any contraception because her husband wants a child right away.
Prior medical history: None. Prior surgical history: None
Current medications: Prenatal vitamins. Allergies: Penicillin
GYN History: Menarche age 10, normal cycle length of 5 days, until recently. Now with irregular cycles
and heavy flow. No history of sexually transmitted infections (STIs). No history of pregnancy. Last cervical
cancer screening was 3 years ago and normal. Performs regular SBE at home.
LMP: 2 weeks ago. Contraception history: None.
Social history: Lives with her new husband. Housewife – husband made her quit her job after they were
married. Admits to 1 – 2 glasses of wine during the day when husband is working. Nonsmoker.
Family history: Mother and father alive and well. MGM alive– breast cancer age 65
Review of Systems (ROS): Unremarkable except for menstrual cycle changes.
Physical Exam (PE)
VS: BP: 109/66, P: 87, RR: 16, T: 97.3, Weight 101 lbs (visit last year was 122 lbs), Height 64”, BMI 17.3
General: Withdrawn, does not make eye contact. Oriented x 3. Appears slightly disheveled and
underweight.
Integumentary: Warm, dry, and intact. Bruise noted to right inner thigh.
Abdomen: Soft, NTND, BS present x 4.
External: Appropriate hair distribution, No lesions or erythema. Speculum exam: No discharge, no
lesions, no cervical motion tenderness (CMT). Bimanual exam: uterus normal size firm and non-tender.
No adnexal masses palpated bilaterally, nontender. Breast exam normal.
Instructions
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.