Patient Information:
Patient’s Name: E.G. , 38, Female
S.
CC: Contraceptive options
HPI:
E.G. is a 38-year-old female, G1 P1 LC 1, who came to the clinic for contraceptive
management. She acknowledges she had three sexual partners this year. She does not want
to desire another child, but her current partner might want a baby in the future. She reported
heavy menstrual cycle that requires her to change tampon every hour. She has a regular
menstrual cycle every 28 to 32 days and last 5 to 8 days. Her last pap smear was normal,
showing negative for HPV and GC/CT culture. She reported she had been on birth control
pills but “would keep messing up.” She has a significant history of exercise-induced asthma,
seizure disorder, & IBS.
Current Medications: Lamictal (lamotrigine), Trileptal (oxcarbazepine)
Allergies: No Known Drug Allergies
PMHx: Exercise-induced asthma, seizure disorder, & IBS
Soc & Substance Hx: Negative for alcohol, tobacco, and recreational drugs
Fam Hx: Family history reveals that her maternal grandmother alive with dementia, while
her maternal grandfather is alive 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.
Reproductive Hx: G1 P1 LC1; Menstrual history (no data [LMP]), pregnant (no),
nursing/lactating (no), contraceptive use (history of birth control pills), types of intercourse
(not stated), and any sexual concerns.
Surgical Hx: Tonsillectomy (childhood)
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: LMP? No complaints of burning on urination.
NEUROLOGICAL: Reported having seizure d/o (last seizure was five years ago) No
headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No
change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
, HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of
splenectomy. PSYCHIATRIC: No history of depression or
anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or
polydipsia.
REPRODUCTIVE: Positive for heavy menstruation. The cervix is negative for CMT, positive
for firm, smooth and parous. The uterus is mobile, about 8 cm, and non-tender. Adnexa is
negative for masses and negative for tenderness.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vital signs:
Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68
General:
EG is alert and oriented (A/O X 4); dressed appropriately. Seated upright in the examination
table. She communicates well, no signs of stress.
HEENT:
Head is normocephalic and atraumatic. EYES: Bilateral eyes with equal hair distribution on
lashes and eyebrows, lids without lesions, no ptosis or edema. No redness, no conjunctival
discharges. EARS: Right auditory canal and tympanic membrane color: erythematous. Left
ear no visible abnormal appearance. No discharges both ears. NOSE: right maxillary sinus
is tender to palpate and percuss. Mouth & THROAT: Oral mucosa is moist and
pink. Neck is symmetric, supple, no
jugular venous distention. No apparent lymphadenopathy and thyroid not enlarged. No
palpable cervical, supraclavicular, and axillary lymph nodes
Pulmonary: Her lungs are clear to auscultation bilaterally, no wheezes, rales, or rhonchi and
good air movement throughout. Breath sounds present in all areas.
Cardiovascular: Chest is symmetric. No chest tenderness to palpation, regular rate and
rhythm, normal s1, normal s2 and no murmurs, rubs, or gallops.
Gastrointestinal: Abdomen is soft to touch. Non-tender, non-distended and with positive
bowel sounds.
Skin: Skin is warm and dry, no diaphoresis. No visible lesions, scars, tattoos or moles.
Genitourinary: VVBSU: WNL, except 1st deg cystocele, CERVIX: firm, smooth, parous,
without CMT; Uterus: RV, mobile, non-tender, approximately 8 cm; Adnexa: without masses
or tenderness
Diagnostic results:
As a nurse practitioner (NP), we have to make sure that the patient is not pregnant, thus
pregnancy test is automatic whenever faced by patients (of reproductive age) having abnormal
uterine bleeding (AUB). I will also order a complete blood count (CBC) with differentials.
CBC will determine level of hemoglobin & hematocrit (H/H), as well as uncovering iron
deficiency anemia due to heavy menstrual bleeding. Due to her history of multiple partners,
an STD test will be covered.
A.
Differential Diagnoses
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