Women’s Health Case Study

Name: MT

Date:12/3/19

Time: 0930

Encounter 2

Age: 32

Gender: Female

PARTICULAR

CC:

“I am in requirement of your assistance to get help with birth control. There are so many choices unfortunately, I do not know which one to take.”

HPI: Female aged thirty two years old who is Asian American applies to the clinic so that she can start birth control.

Prescription: (reasons for prescription)

PT is not taking any medication currently

PMH: None

Allergies: Does not have any nutriment or medicine antipathies

Suppository Prejudices: None

Prolonged Sicknesses/Main traumas:

Patient rejects to any therapeutic disturbance

Enduring Health Problems: No identified fleeting health complications

Hospitalization/Surgical procedure: Not known.

Family History: Mother Healthy. Father HTN. Sister Healthy. Brother autism

Social History:

Societal antiquity is nil for ETOH where she repudiates present and, or past use of illicit drugs and she negates current use of tobacco. Also, she claims to do exercise on a regular basis but not on any specified diet. Currently , Pt is in Financial accounts class

ROS

General:

The pt repudiates fatigue, fever, night sweats, chills, weight change and energy level.

Cardiovascular:

She repudiates any experiences of syncope, palpitations, chest pain or orthopnea.

Skin:

The patients denies any signs of skin abrasions.

Respiratory:

The patient disagrees to have dyspnea and cough

Eyes:

Patient states no alterations in blurred visualization or dual vision.

Abdominal:

Patient denies having nausea, vomiting any bowel changes change in hungriness

Ears:

No recent discharge from ears, pressure loss of hearing and tinnitus

Genitourinary/Postnatal:

Patient denies any itching, burning or discharge

Last PAP: 9/11/18

Mammogram: 11/2/18

Gestation: G4P3

Not on any contraception, is currently sexually active. Has had one partner. No STD history.

LMP: 4/21/19

Nose/Mouth/Throat:

Denies any form of discharge and running nose.

Denies any struggle swallowing or tender throat

Musculoskeletal:

Denies any dimness.

Breast: Denies any lumps or tenderness

Neurological:

Patient denies any syncope, seizures or weakness.

Heme/Lymph/Endo:

Denies any hurting puffy glands and night sweats.

Psychiatric:

Denies nervousness or sleeplessness and suicidal intentions.

OBJECTIVE

Weight: 125 lbs

BMI: 21.5

Temp: 98.9

BP: 132/75

Height: 5’2”

Pulse: 83

Resp: 18

General Look:

Normotensive, the Asian female who is sitting on examination table in not having acute agony. She is nicely dressed and accommodating with a lovely touch.

Skin:

Warm and dry with no rashes and lesions noted.

HEENT:

Normocephalic, there is no abrasions. Pupils are equal, round, sensitive to beam of light. Tympanic membranes are somber, not bulged and without erythematous. Mucosal is pink and moist.

Neck: There is no jugular intravenous distention and palpable masses.

Cardiovascular:

There is regular rhythm, tachycardia, S1 and S2. Gallops, S3, S4, rubs and murmurs were not felt.

Respiratory:

The breath is clear, sounds consensually, no difficulty in breathing and coughing.

Gastrointestinal:

Not puffy, hypoactive bowel which sounds okay in all 4 quadrants.

Genitourinary/Gynecological:

Bladder is not distended and CVA is not tender

External genital tells coarse pubic hair in usual scattering and there is no abrasion noted.

Musculoskeletal:

Peripheral pulses is perfectly responding and capillary replenish is less than two seconds as well as no edema.

Neurological:

Speech is vibrant comprehensible and stable gait.

Psychiatric:

Patient is focused person with place, time and setting and she is well dressed.

Lab Tests

Urinalysis – waiting for results

Pregnancy test – negative

Specials Tests

N/A

Differential Diagnosis:

Z30.018 Encounter for initial prescription of other contraceptives

Plan/Therapeutics

Non-pharmacologic treatment: Waiting egerly

Pharmacologic treatment: Depo-Provera or DMPA is vaccinated with intervals of 12 weeks making it an intermediary contraceptive that works effectively. It is estrogen-free and has low conservation possibility (Perry, 2016). The combination oral contraceptive pills are in the first line therapy for females who have knowledge of heavy, and or lengthy bleeding, occasional or aching menses, recurrent luteal phase ovarian polyps, cancerous history in the family, endometrial cancer risk factor and polycystic ovary syndrome (Slomski, 2017). Pills usage can fair compare to injections. 

Education: Patient training is aimed at signs and symptoms to pursue medical care for changes like menstrual cycle, prevailing pelvic pain, distress in abdomen. Also, patient need to be educated about injection contraceptives requires to be monitored after every three months. Using condoms always reduces the rate of contracting STIs

Not allowing referrals at the moment.

The assessment of this particular patient was of help to education and administration of Gynecological anomalies.