Case Study 2Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your clinic today to discusscontraceptive options. She states that she is not interested in having more children but her newpartner has never fathered a child. Her medical history is remarkable for exercise-inducedasthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Hersocial history is negative for alcohol, tobacco, and recreational drugs. She has no known drugallergies and takes only vitamin C. Hospitalizations were only for childbirth. Family history revealsthat her maternal grandmother is alive with dementia, while her maternal grandfather isalive 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 skincancer (basal cell). Elaine has one older sister with no medical problems and one youngerbrother with no reported medical problems.Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68HEENT: wnlNeck: supple without adenopathyLungs/CV: wnlBreast: soft, fibrocystic changes bilaterally, without masses, dimpling or dischargeAbd: soft, +BS, no tendernessVVBSU: wnl, except 1stdegree cystoceleCervix: firm, smooth, parous, without CMTUterus: RV, mobile, non-tender, approximately 10 cm,Adnexa: without masses or tendernessEpisodic focused Note- Contraceptive optionsPatient Information: E.G., 38y.o. female, race unknownS.CC: discuss contraceptive optionsHPI: E. G. is a 38 y.o. female who presents to office to discuss contraceptive options. She isG5P5LC6. 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 allergiesPMHx: exercise- induced asthma, migraines, irritable bowel syndromePreview Mode
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