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Case Study 1
Case Study: Contraception
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 1st degree cystocele
Cervix: firm, smooth, parous, without CMT
Uterus: RV, mobile, non-tender, approximately 10 cm,
Adnexa: without masses or tenderness
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QUESTION
Based on the case study scenario provided, complete a comprehensive well-woman exam and critically analyze to focus attention on the diagnostic tests then,
Post your differential diagnosis. Include the additional questions you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations.
SCIENCE
HEALTH SCIENCE
NURSING
