History of Present Illness
History of Present Illness
Dolores Sanchez is a 16 yo female scheduled for a contraceptive visit. “I want to discuss birth control today. I have a boyfriend and have been using condoms for a while, but I want something more effective. Some of my friends use the shot and have gained weight. Will the pill make me gain weight?” Dolores states that she has been having intercourse on an infrequent basis over the past year. Now she has a steady partner and is having intercourse approximately twice a week for the past two months. Dolores states that she is currently having a regular, normal period that started 3 days ago. Dolores goes on to say that although she has heard about birth control methods such as the implant and IUDs, her older sister uses the pill and likes the pill as a method. Dolores assumes that she, too, will do well with the pill.
Medical History
No hospitalizations, surgeries, or major medical problems. She has had all of the usual childhood immunizations: MMR, Hepatitis B, varicella, IPV, HIBPCV13, DTaP series as a child, and Tdap booster at age 11. She started the HPV series with the first dose given one year ago. She did not return for subsequent doses.
Family Medical HistoryMGM: 72 yo (breast cancer, treated with radiation) MGF: 73 yo (lung problems, smoker)PGM: 70 yo (hypercholesterolemia) PGF: Deceased at age 69 yo (MI) Mother: 40 yo (asthmatic, smoker)Father: 42 yo (HTN, hypercholesterolemia)Siblings: Two brothers, 14 yo and 12 yo; sister 18 yo (all healthy)
Social History
Smokes one-half pack per day. She had her first cigarette at age 13. Had smoked infrequently until last year when she began to smoke regularly with her friends. Is a sophomore in high school; enjoys school and maintains a B grade average. Is not involved in school sports other than physical education class twice a week. On yearbook committee. Lives at home with both parents. Works part-time in a convenience store. Denies drug use; occasional beer with friends. CAGE questions: Negative responses. Uses seatbelts. Denies history of intimate partner violence.
Medications
Occasional ibuprofen 400 mg for menstrual cramps
Allergies NKDA
Review of Systems
General: alert, healthy-appearing young female
HEENT: Ear infections as a child but not since age 10; denies asthma, hay fever, frequent colds, nasal discharge, sinus problems; no dental problems, but does not have regular preventive dental care
Cardiovascular: No history of heart murmur or heart problems
Respiratory: Denies any difficulty with breathing, asthma, or bronchitis
Abdominal/gastrointestinal: Denies heartburn, abdominal pain, constipation, diarrhea, rectal bleeding; no history of liver or gallbladder disease
Genitourinary: Menarche, age 12; menses, regular 28- to 30- day cycles, lasting 5 days, describes flow as moderate for 3 days, lighter for 2 days; experiences cramping on day 1 of cycle for which she uses ibuprofen 400 mg 2 to 3 times a day for 1 day with relief of cramping; denies intermenstrual or postcoital bleeding or dyspareunia; first intercourse at age 15 ½; two sexual partners, infrequent intercourse until 2 months ago; no complaints of vaginal discharge, itching, burning, or urinary dysuria or frequency; LMP started 1 week ago, normal menses, has not had intercourse since LMP; is planning on becoming more sexually active with current partner
Neurological: Headache on first day of menses that is relieved by the ibuprofen; no other complaints of headaches, no history of migraines; no history of seizures
Endocrine: States she is fatigue on the three days a week that she works after school because she must stay up late to finish homework; is not fatigued if she has 8 hours of sleep at night; no history of diabetesMusculoskeletal: No complaint; no history of injuries, muscle pain, or joint pain
Physical ExaminationVital signs: Temperature 98.2 F; BP 120/62 mm HgHeight: 66 inches Weight: 160 lbs. BMI: 25.8
After reviewing the case and grading rubric, please answer the following:
1. Learning Issus (Before identifying your recommended Assessment and Plan, identify any learning issues that you believe are important for you to explore about this case):
2. Assessment (Please indicate the problems or issues you have identified that will guide your care [preferable in list form]):
3. Plan (Please list your plans for addressing each of the problems or issues in your assessment making sure to utilize references to support your plan)
Differential Diagnosis
Points:
10 (10.00%)
Lists 3 differential Dx for the health issue
Pathophysiology
Points:
20 (20.00%)
Discusses the pathophysiology of the most likely health issue presented.
Issues
Points:
15 (15.00%)
Presents the cultural, ethical, and/or legal issue(s) and how it may conflict with the patient care/health promotion
Interventions
Points:
20 (20.00%)
Provides patient-centered pharmacological and/or non-pharm solutions to the health issue
Referrals
Points:
15 (15.00%)
Provides a comprehensive list of additional health services available and may be needed
Provider Implications
Points:
10 (10.00%)
Reflects on how the cultural or ethical issue mirrors/contradicts your own beliefs and how this may impact your care as a provider
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