Contraception case study

Women’s Health Nurse Practitioner Case Study Template Author’s Name The Institutional Affiliation Course Number and Name Instructor Name Assignment Due Date Patient Information Name: Jessica Age: [30 years] Chief Complaint: [The patient detects spots between her periods; she is interested in long-term management of contraceptives.] History of Present Illness (HPI) (OLDCARTS should be used if the patient has a complaint.) Duration: [She has been taking contraceptive drugs for many years, but she has started to identify some spots between her periods only recently ] Onset: [The appearance of spotting is only occasional, as Jessica sees only between her periods] Location: [The problem is located in the vagina, which experiences occasional bleeding.] Quality: [The bleeding appears in the form of spots.] Aggravating/Alleviating Factors: [May be a lack of regularity in the use of contraceptive pills] Associated Symptoms: [Jessica does not report any other related symptoms] Patient History: Past medical history: [Jessica has been experiencing migraines for a long time; she had a pap smear last year, and the result was LSIL. There was no detection of abnormalities in cervical culture. The patient has been taking oral contraceptive pills. The name and dosage of pills are unknown. She may be taking pills for the treatment of migraine] Past Surgical History: Jessica had no surgery in the past. Reproductive history: [Jessica has past pregnancies and three living children; she experiences scheduled withdrawal bleeding during her menstrual cycles due to the use of oral contraceptive pills. She is interested in using long-acting contraceptive pills.] Sexual history: [Jessica is sexually active. She has monogamous sex with her husband for the last five years. She has never experienced any sexually transmitted infection.] Social history: [Jessica is a regular smoker; she smokes half a pack per day. She is also a social drinker, but the frequency of her alcohol use is not determined. She has no history of use of illegal drugs or substance abuse. Jessica lives with her family, and she is engaged in full-time work and does exercises only occasionally. She is also a student of graduate school] Family Medical history: [No specific family history is available] Review of Systems (ROS) General: [Jessica does not experience fever or abnormal change in body weight. She experiences work-related fatigue] Head/Eyes/Ears/Neck/Throat: [No specific symptoms, eyesight or hearing problem, or sore throat; Jessica has a history of migraine] Cardiovascular: [Jessica does not experience any chest pain or palpitation] Respiratory: [Jessica does not experience breathing difficulties or regular coughing.] Gastrointestinal: [Jessica does not report any abnormal abdominal pain or nausea] Genitourinary: [Jessica does not report pain or burning during urination or any urgency; she does experience spotting between successive periods] Musculoskeletal: [Jessica does not experience any muscular pain or mobility difficulty] Neurological: [Jessica does experience migraine, but her headaches are without dizziness or focal weakness] Psychosocial: [Jessica admits experiencing stress and workload due to professional obligations and graduate school responsibilities. She does not feel anxious about the possible side effects of using long-acting contraceptives. Physical Examination Vital Signs: [ BP 126/88 mmHg, Heart Rate: to be obtained, Respiratory rate: to be obtained; temperature: to be obtained] General appearance: [Jessica has a physically fit and strong body with no signs of malnourishment; no signs of acute distress; her height is 5’3”, and she weighs 180 lbs with a body mass index of 31.9 kg/m² Focused Physical Exam: [Performed based on patients’ consent.] Head/Eyes/Ears/Neck/Throat: normal functioning Cardiovascular: regular heartbeat and rhythm (78 bpm) Respiratory: normal breathing (16 breaths per minute) Gastrointestinal: normal appearance and function) Genitourinary: (normal appearan...