patient case study

The patient is a 25-year-old healthy female with no known medical history. When the patient was 21, she received her first Pap smear test. It was performed in March 2014, and the results showed that she was normal. Before, the patient claimed to have two sexual partners, but she is now in a serious relationship with only one. She and her partner only use condoms as a form of contraception. Current Medication: hydroxycholécalciférol, 1 alpha (OH) D3.One tab per day.Allergies: The patient is allergic to peanuts

Immunization Status: The patient is up to date on all her vaccines. A possible FLU shot vaccine and HPV vaccine to be offered today.

Previous Tests: Normal Pap smear test. The patient shows negative signs of sexually transmitted diseases (STD).

Childhood Illness: The patient suffered from chicken pox while she was seven years old.

Major illness as an adult : N/A

Injuries: The patient says that she broke her hand on the school field while she was ten years old.

Surgeries: N/A

Family history

The patient’s mother has a history of breast cancer she was diagnosed at 46 years old. The mother underwent radio therapy and lumpectomy. Since she detected it early, she is currently doing fine while taking the aromatase inhibitor. The patient claims of no other family medical history.

Social History

The patient is a personal assistant to the CEO at Blackstone International and also perusing her master’s degree. She eats healthy and exercises daily.

ROS

General: Denies checking for fever, no chills or fatigue, no recent weight loss or weight gain, no night sweats, no loss of appetite, no difficulty in sleeping.

HEENT: Nose, Ears Mouth, and Throat: No headaches, no vertigo, dental problems, nasal congestion, epistaxis, hoarseness, oral lesions, sinus problems. Eyes: patient denies difficulty in focusing, diplopia, blurred visions, and peripheral visual change.

NECK: Denies the feeling of swollen lymph nodes, goiter or pain to the neck

RESPITORY: Denies coughing, wheezing and difficulty in breathing

GENITOURINARY: Denies heavy bleeding and incontinence, dysuria, last LMP was 2 weeks ago. The first period was at the age of 14.regular periods received monthly.

CARDIOVASCULAR: Denies any chest pain, palpitations, syncope or irregular heart rate. Reports no dyspnea, edema. Reports no echocardiogram performed.

NEURO: Reports no seizure or weakness. Denies fainting, blackouts, seizures. Reports no vertigo

OBJECTIVE

Vitals: BP-110/66, Temp-98.8, HR-67, Height-5’6’, Weight-179 Ibs. General appearance; the patient appears to be healthy, well developed and nourished.Distress level; NAD.Ambulation; Normal

Eyes: PERRLA, no ptosis, Light reflex present both direct and consensual. No retinal lesions or hemorrhages. No orbital edema. Ears: EAC’s clear. TM no erythematous, bulging or dullness. External auditory canal intact without deformities. Nose: No edematous turbinates, clear rhinorrhea. No nasal tenderness. Throat: Clear, no exudates, no lesions. No odor to breath. Uvula midline with no tonsil enlargement

NECK: Trachea midline, no tenderness to thyroid, no bruits heard to carotids. No enlarged lymph nodes palpated.

GENITOURINARY: No dissertations noted, external genitallia looks normal, no bladder tenderness noted upon palpation, no gross lesions or laceration, healthy pink is seen at the vagina, pink mucosa, white discharge noted, wet prep has normal results.

NEUROLOGICAL: The patient’s communication is normal, attention and concentration normal, the patient’s sensation of gait and light is normal.

CARDIOVASCULAR: No murmurs, gallops or rubs, S1, S2 regular rate and rhythm.

IMMUNOLOGICAL: No bruising or bleeding is noted, no tenderness or masses present, lymph nodes not palpable.

LAB TEST

Wet prep: Normal

Pap smear: In waiting

Assessment

Pap smear-routine gynecological exams

After reviewing the patient’s records, it was wise that the patient came in for her routine pap smear. The patient is sexually active and on oral contraceptives thus the Pap smear is recommended.

Family planning-council and advice on contraceptive management

The patient has requested a refill on her birth control pills and has clarified her use of the pills when she occasionally misses a dose of medication (Tharpe & Jordan, 2013).

Plan

The Pap smear was performed without difficulties. The sample was sent to the lab, and the results are pending. The patient is aware that she will receive her results at home through the mail. If the results are abnormal, she will be contacted.

Tri Sprintec, one pill per day refills. The patient is encouraged to continue using birth controls. It is important to take the medication as planned and to maintain one sexual partner (Schuiling & Likis, 2013).

Reflection

I have learned that the treatment of acne vulgaries in females above 15 years don’t have any contraindication to oral contraceptive therapy. The desires to use oral contraceptives as a method of birth control have achieved menarche. I have also learned that the combination of oral contraceptives primarily inhibits ovulation, suppresses gonadotropins and causes other alterations such as endometrium(reducing the likelihood of implantations), increases sex hormones, by binding globulin and decreasing free testosterone and causes a change in the cervical mucus.(reducing the entry chances of sperms into the uterus.

I also agree with the plan of birth control pill since it is generic, easily affordable and available.

Patient Education

If a dose is missed, take one pill as soon as possible. If two doses are missed, take two pills immediately then continue with the usual dosage of one per day.

Oral contraceptives (OCs) do not prevent STDs or HIV/AIDS.

Certain medications such as antibiotics and antidepressants decrease the effects of the OCs. If placed on any new medication ensure a follow-up is done.

Oral contraceptives can cause DVTs, thus avoid smoking since it increases the chances (Kling et.al, 2017).

References

Kling, J. M., Vegunta, S., Al-Badri, M., Faubion, S. S., Fields, H. E., Shah, A. A. ... & MacLaughlin, K. L. (2017). Routine pelvic examinations: A descriptive cross-sectional survey of women’s attitudes and beliefs after new guidelines. Preventive Medicine, 94, 60-64.

Schuiling, K. D., & Likis, F. E. (2013). Women’s Gynecologic health (2nd Ed.). Burlington, MA: Jones and Bartlett Publishers.

Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for Midwifery & Women’s health (4th Ed.). Burlington, MA: Jones & Bartlett Publishers.