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NRNP Case Study 2 Week 3 (1 Solved Case)

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    Case Study 2 Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your clinic today to discuss contraceptive options. She states that she is not interested in having more children but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs. She has no known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Elaine has one older sister with no medical problems and one younger brother with no reported medical problems.  Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68  HEENT: wnl  Neck: supple without adenopathy  Lungs/CV: wnl  Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge  Abd: soft, +BS, no tenderness  VVBSU: wnl, except 1 st degree cystocele  Cervix: firm, smooth, parous, without CMT  Uterus: RV, mobile, non-tender, approximately 10 cm,  Adnexa: without masses or tenderness Episodic focused Note- Contraceptive options Patient Information: E.G., 38y.o. female, race unknown S. CC: discuss contraceptive options HPI: E. G. is a 38 y.o. female who presents to office to discuss contraceptive options. She is G5P5LC6. She does not really want another child, but her new partner has not fathered a child. Current medications: Vitamin C (dosage and frequency unknown) Allergies: No known drug, food, and environmental allergies PMHx: exercise- induced asthma, migraines, irritable bowel syndrome

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    Vaccination history (unknown) Hospitalizations for childbirth (unknown if any complications occurred, length of stay) Social and Substance Hx : Patient denies smoking, drinking alcohol, and use of recreational drugs. Family Hx: Dad: alive- Basal cell skin cancer Mom: alive- osteopenia, fibromyalgia Paternal grandparents: deceased- cause: car accident Maternal grandmother: alive- dementia Maternal grandfather: alive- COPD Sister (older): alive- no medical problems Brother (younger): alive- no medical problems Past surgical history : tonsillectomy (childhood) Mental Hx : no data available Violence Hx : no data available Reproductive Hx : G5P5LC6, no info on LMP, length of menstrual cycle, dates of previous pregnancies, history of complications with childbirth ROS : (not obtained) only information collected is

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