Clinical Case Analysis 1

Location: STAR Health

Reason for visit/Chief Complain:  35 year-old woman who presents for a contraceptive management appointment. She is here for her annual visit and is requesting to refill her birth control pills. She states that she is happy with her current method of contraception and does not plan to have any more children. LMP 08/4/18. She reports regular monthly menses on her birth control pills with no breakthrough bleeding.

 History:

• FMH: Her mother was diagnosed with breast cancer at the age of 55, is now 59 and "is doing well." Her father had a "mild heart attack" at the age of 41 and is presently on medication for hyperlipidemia.
• Medical History: "Mono" at 16 years of age. No other significant illnesses.
• Allergies: NKDA.
• Medications: Sprintec-28, 1 po daily since the birth of her last child.
• Hospitalizations: 2 vaginal deliveries 2013, 2016.
• Surgery: None
• OB History: G2 P2002 2016: SVD viable male infant at term, mild gestational hypertension but "no medication needed."
• 2013: SVD viable female infant at 38 weeks gestation after induction of labor for preeclampsia. Magnesium sulfate was used intrapartum and 24 hrs. postpartum.
• GYN History: HPV diagnosed with an abnormal Pap in January 2012; results: ASCUS HPV positive. Colposcopy was done at Planned Parenthood in 2012, results were normal. Her last complete gynecological exam was done with her Pap smear in September of 2016: results normal pap, negative HPV
• Menarche age 12x28x5 days. LMP 08/4/18
• Social History: Occasional ETOH, states she "has a glass of wine every other weekend." Smokes 15-20 cigarettes per day for 15 years. Denies drug use. She is married x 14 years and works as a pharmacist's assistance in Walgreen's, and states they are monogamous. She feels safe in her home and in her relationship with her husband.

Physical Exam

Height 66 inches, Weight 160 lbs., BP 120/80

Clinical Case Analysis 1

1. H&P: What other questions/ history/ physical exam do you need to obtain? (Include information that you add in this section in italics). Include all of the information given in this case study, as well. Describe what you would include in the physical examination on this patient. Explain your rationale/ current guidelines for the specific parts of the H&P.
2. Assessment (and differential diagnoses, if any) for this patient.
   1. Include CDC MEC
3. Plan
   1. What diagnostic tests, if any, would you obtain or order for this patient? Explain your rationale/guidelines for obtaining or ordering the diagnostic test.
   2. What method(s) of contraception would be appropriate for this patient? List all options with appropriate teaching for all possible methods, including how/when to start each method. Include approximate cost, effectiveness and CDC MEC categories for each method. This section should be a minimum of six pages.
   3. What additional patient teaching should be included?
4. Format: Arrange paper in a SOAP note format, using APA format for references, cover sheet, etc. Be sure to include all information given in the history.   It should include a reference list with at least two references from APRN peer-reviewed journals, attached as a pdf. Appropriate IDC-10 and CPT coding should be listed following the plan of care. Minimum 10 pages.