PLEASE USE ATTACHED TEMPLATE WHEN COMPLETING ASSIGNMENT AND PEER REVIEWED ARTICLES
Case #1. Teresa.
History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your office
today at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure to
progress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital on
day 2 post-partum without complications. Teresa has had difficulty with breast feeding due to
discomfort in her suture line and terrible pain in her right breast since her discharge from the hospital.
She reports occasional chills- she has not measured her temperature at home. Teresa was seen by the
lactation consultant while in the hospital but “nothing is working” and her son “cries all the time”. She
is afraid to feed her son formula as her mother-in-law wants her to “keep trying to breastfeed”. Teresa
tells you she feels as if she has failed her son- “it was so easy with my first baby, I know my husband
thinks I am a bad mother”.
Prior medical history: None. Prior surgical history: Appendectomy (2000)
Current medications: Prenatal vitamins, stool softener. Allergies: None
OB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.
Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history of
sexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by a
normal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.
LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history:
Oral contraceptives, condoms.
Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH or
recreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.
Family history: Unremarkable.
Review of Systems (ROS): Negative except as noted in HPI.
Physical Exam (PE)
VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.
Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge or
lesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam,
you do note an erythematous, swollen, and painful area to the right breast. Her physical exam is
otherwise unremarkable.
RUBRIC:
The response provides clear, complete, and comprehensive descriiptions of subjective and objective case data, appropriately outlining all diagnostic tests, clinical procedures and pharmacological interventions.
The response contains at least 3 differential diagnoses relevant and applicable to the case.
Formulates 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.