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Respond to this case study explain how you might think differently about the typ

by | Jun 18, 2022 | Nursing | 0 comments


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Respond to this case study explain how you might think differently about the types of tests you might recommend and explain why. Use your Learning Resources and/or evidence from the literature to support your position. Patient Information: EG, 38-year old Caucasian female S. CC (chief complaint): “I’m here to discuss birth control options” HPI: 38-year old female reports to clinic for annual well woman exam and to discuss contraceptive options. No acute distress reported. Denies any present pain. Immunizations up to date. Current Medications: Vitamin C 75 mg PO daily Allergies: NKDA PMHx: Immunizations UTD. Hx of exercise-induced asthma, migraines and IBS. Previous hospitalization for childbirth-spontaneous vaginal delivery. Soc & Substance Hx: Denies tobacco, alcohol and illicit drug use. Fam Hx: Maternal Grandmother: Alive, dementia Maternal Grandfather: Alive, COPD Paternal Grandmother: Deceased, MVA Paternal Grandfather: Deceased, MVA Mother: Alive, osteopenia and fibromyalgia Father: Alive, basal cell carcinoma Sister: Alive, no known medical problems Brother: Alive, no known medical problems Surgical Hx: Tonsillectomy during childhood Mental Hx: No history of self-harm practices and/or suicidal or homicidal ideation. Violence Hx: No concern or issues about safety Reproductive Hx: LMP 5/1/22, no irregular periods reported. GTPAL 11001. Currently uses condoms for contraception but interested in other options. Sexually active. Practices monogamy. No recent change in partners. No hx of STD/STI. ROS: GENERAL: No weight loss, fever, chills, weakness, or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness. HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia. GENITOURINARY/REPRODUCTIVE: No burning on urination. Pregnancy GTPAL 11001 LMP: 05/01/2022. No breast-lumps, pain, discharge. No reports of vaginal discharge, pain. Currently sexually active. Practices monogamy. No recent change in partners. No hx of STD/STI infection. ALLERGIES: No history of asthma, hives, eczema, or rhinitis. O. Physical exam: Vitals: Pain 0, Ht 67, Wt 148, BMI 23.1, BP 118/72, HR 68, SaO2 98, Temp 98.0 General: Adequate personal self-care, no acute distress, pleasant. HEENT: No head or facial abnormalities. Neck/Thyroid: Normal implantation and mobility. No deformities. Supple Thyroid not visible or palpable, no mass. CV: Regular cardiac rate and rhythm, normal S1 S2, no murmurs. Chest with normal configurations. No deformities. Respiratory: Respirations even and unlabored, symmetric respiratory movements. Lungs CTA all fields. No adventitious breath sounds. GI: No bruit, no guarding, no hepatosplenomegaly, no hernias present, no masses palpated, no rebound, no rigidity, non-distended, soft, non-tender, no organomegaly, normal bowel sounds. GU: No pelvic adenopathy. No lesions, sores, rash, or cysts noted. No vaginal discharge. Vaginal wall: no lesions, no adherent discharge, well-rugated, well-estrogenized. Cervix: pink, no lesions, no purulent discharge noted, clear and shiny coating of cervix noted. Bimanual exam: No adnexal, uterine or cervical tenderness noted. No masses or cysts noted. Breasts: Soft, fibrocystic changes bilaterally. No masses, dimpling or discharge present. Musculoskeletal: No clubbing, no edema, no cyanosis, normal ROM, arterial pulses present. Psychiatric: A/O x4, normal affect, communicative, normal speech pattern, good eye contact. Diagnostic results: UA Urine HCG Screening breast exam Lab: Pap with HPV A. Primary and Differential Diagnoses Encounter for gynecological examination without normal findings Z01.419 Screening breast examination Z12.39 Encounter for counseling regarding contraception Z30.09 P. Discuss the Nexplanon, the 3-year implant to prevent pregnancy. NEXPLANON is a long-acting (up to 3 years), reversible, hormonal contraceptive method. The implant must be removed by the end of the third year and may be replaced by a new implant at the time of removal, if continued contraceptive protection is desired (Mommers et al., 2012). Advise against hormonal oral contraceptive use related to PMH of IBD and migraines and family history of osteopenia. Currently, there are no recommendations regarding contraceptive use by women with IBD in the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use (MEC) (Zapata et al., 2010). Instruct to continue with monthly SBE, annual pap smear, refer for screening mammogram. Follow up in 2 weeks. References Mommers, E., Blum, G.-F., Gent, T. G., Peters, K. P., Sørdal, T. S., & Marintcheva-Petrova, M. (2012, August 10). NEXPLANON, a radiopaque Etonogestrel implant in combination with a next-generation applicator: 3-year results of a noncomparative multicenter trial. American Journal of Obstetrics and Gynecology. Retrieved June 15, 2022, from Sivin, I. (2007, April 16). Utility and drawbacks of continuous use of a copper T Iud for 20 Years. Contraception. Retrieved June 15, 2022, from Zapata, L. B., Paulen, M. E., Cansino, C., Marchbanks, P. A., & Curtis, K. M. (2010, March 29). Contraceptive use among women with inflammatory bowel disease: A systematic review. Contraception. Retrieved June 15, 2022, from

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