Case Study: Contraception Options
Case Study: Contraception Options Scenario 1
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. Case Study: Contraception Options
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 Case Study: Contraception Options.
- 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
QUESTION:
What other information do you need?
MORE QUESTIONS:
- What has she used in the past? Why did she stop a method? How many partners in past 12 months?
- What are her current cycles like?
- When was her last gyn exam and what were the results of the tests?
- Are her migraines with or without auras?
- What method has she considered.
QUESTIONS:
•What are your next steps/considerations?
•;What teaching should you do?
•What methods are appropriate for Elaine?
NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.” Case Study: Contraception Options
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed. Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Case Study: Contraception Options
Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Case Study: Contraception Options
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), and any sexual concerns. Case Study: Contraception Options
ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. LMP: MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.