Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests you might recommend and explain why.
Response 1
Patient Information:
E.G., 38, Female
S.
CC “discuss contraceptive options.”
HPI: 38-year-old female presents to the office to discuss contraceptive management options. She is a G5P5006. She denies wanting anymore children, but her partner has never fathered a child. She has a history of migraines. She is currently not using any form of contraceptive.
Current Medications: Vitamin C
Allergies: NKDA
PMHx: Positive for exercise-induced asthma, migraines, and IBS. Surgeries: Tonsillectomy. Hospitalizations: childbirth.
Soc Hx: Denies use of alcohol, tobacco, and recreational drugs. She is in a relationship with new partner who does not have children.
Fam Hx: 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.
ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Shortness of breath with exercise. Denies cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, or vomiting. Positive for occasional abdominal pain and diarrhea due to IBS. Denies abdominal pain and diarrhea today.
GENITOURINARY: Denies burning on urination. Last menstrual period: unknown.
NEUROLOGICAL: Positive for migraines. Denies dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: History of exercise-induced asthma. Denies history of hives, eczema or rhinitis.
O.
Physical exam:
VS: Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68
GENERAL APPEARANCE: alert, in no acute distress.
HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctivae are clear without exudates or hemorrhage. Ears: Hearing intact. Nose: Nares patent bilaterally. Throat/Mouth: Oral mucosa pink and moist.
NECK: Supple without adenopathy
CARDIOVASCULAR: S1 and S2 heart sounds. No murmur or abnormal heart sounds auscultated. Apical pulse 2+. Radial pulses 2+ bilaterally.
RESPIRATORY: Lung sounds clear in all lobes.
BREAST: Soft, fibrocystic changes bilaterally, without masses, dimpling or discharge.
ABDOMEN: Bowel sounds present in all quadrants. Soft, no tenderness noted.
VVBSU: 1st degree cystocele
CERVIX: Firm, smooth, parous, without CMT.
UTERUS: RV, mobile, non-tender, approximately 10 cm.
ADNEXA: Without masses or tenderness
Diagnostic results: Urine HCG test, Pelvic exam, breast exam, PAP smear (if due), STI testing if requested.
A .
Differential Diagnoses:
1. Encounter for other general counseling and advice on contraception-This is a good differential diagnosis, if the patient only wants to discuss contraceptive management today and take time to decide which one she prefers. She may also want to talk to her partner prior to starting. I would highly suggest contraceptive management, since she has a cystocele and she does not want more children, but her partner does. Dietz, Shek, and Low’s (2022) study revealed that women with a cystocele are more likely to have a partial avulsion during pregnancy.
2. Cystocele-This is a secondary diagnosis because it was found on exam. She needs to be referred to pelvic floor therapy.
3. Encounter for contraceptive management-This is a great differential diagnosis, because it covers a variety of contraceptive options and she wanted to start contraceptives. I would highly recommend the use of contraceptives to avoid pregnancy until the cystocele improves. Also, her partner may try to persuade her to have another baby when she is not ready for one right now. Since she has migraines and I do not know her migraine symptoms, I would recommend starting progesterone-only oral contraceptives, DEPO shot, or an IUD. Lodi and Advani (2018) state, “the association between hormonal contraception and stroke risk is estrogen dose-dependent and use of combined hormonal contraception increases the risk of stroke in women with any type of migraine”.
4. Counseling and instruction in natural family planning to avoid pregnancy-This would be a differential diagnosis if the patient does not want to use any type of contraceptive, but instead wants to do natural family planning. Hassoun (2018) states that this is the least effective method of preventing pregnancy and requires extensive education.
5. Malposition of uterus-This could be a differential diagnosis because her uterus is RV. She would benefit from pelvic floor therapy if she is experiencing any pain or discomfort.
Encounter for other general counseling and advice on contraception -Contraceptive options discussed in detail. Patient advised to avoid pregnancy at least until cystocele improves. Progesterone only oral contraceptives, DEPO shot, and IUD discussed as options for birth control due to migraines. Patient would like to think contraceptive options over at home. Will call when she decides. Discussed starting Norethisterone 5mg tablets 1 tab once a day for 28 days, Depo shot every 3 months, or Mirena IUD insertion every 5 years. RTC in 2 weeks for encounter for contraceptive management or sooner if needed.
Cystocele- Patient advised to start pelvic floor therapy due to cystocele. Referred to pelvic floor therapy. Patient advised to avoid pregnancy at least until cystocele improves.
Malposition of Uterus-Start pelvic floor therapy. Referral sent to pelvic floor therapist.
Response 2
Patient Information:
E.G, 38, F, Caucasian
S.
CC “discuss contraception options”
HPI: E.G. is a 38y/o White Female, G5 P5006, with pmh + for exercise induced asthma, migraines, IBS and tonsillectomy as a child, who presents today to discuss contraception options. E.G. is in a new heterosexual, monogamous relationship with her boyfriend and states although her boyfriend has never fathered a child, she is not interested in having more children.
Current Medications: OTC Vitamin C daily, unknown dosage, pt states she has been taking it for last few months.
Allergies: No known drug allergies. No known environmental allergies, No known food allergies.
Immunization status: up to date on childhood vaccination. Last tetanus shot 2019 for her job.
Soc & Substance Hx: denies current and past alcohol use, denies current or past tobacco use, denies current or past recreational drug use.
Fam Hx: maternal grandmother: alive, dementia. Maternal grandfather: alive, copd. Paternal grandparents both deceased from mva. Mother: osteopenia, fibromyalgia. Father: basal cell skin cancer. Older sister: no medical problems. Younger brother: no medical problems.
Surgical Hx: tonsillectomy as a child.
Mental Hx: denies
Violence Hx: denies
Reproductive Hx: G5 P 5 0 0 6
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.
NEUROLOGICAL: sometimes get migraines. No 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.
GENITOURINARY/REPRODUCTIVE: No burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active?
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Well-nourished appearing female. 5’7”, 148lbs (67.1kg), BMI 23.1
118/72 right arm, sitting, manual. 68 regular rhythm, 16 respirations, easy, unlabored. 98.0 oral temp. spa02 99% room air.
HEENT: NECK: supple without adenopathy.
Lungs: respirations easy and unlabored, chest wall symmetrical, no use of accessory muscles. Lung sounds are clear to all fields, no wheezing appreciated.
CV: S1 S2, regular rate and rhythm, no murmurs, gallops, clicks or friction rubs heard.
Breasts: soft, fibrocystic changes bilaterally without masses, dimpling or discharge
Abdomen: soft, + bowel sounds, non-tender
VVBSU: normally appearing external genitalia, no lesions. 1st degree cystocele noted. Cervix: firm, smooth, parous without Cervical Motion Tenderness. Uterus: Retroverted (RV), mobile, nontender approximately 10cm. Adnexa: without masses or tenderness.
Additional questions related to hpi/cc I would ask:
What age were you at menarche debut? When was your LMP? How are your cycles? Regular? Irregular? When was your last pelvic examination? When was your last pap? Have you ever had abnormal findings on your pap/pelvic examinations? How many lifetime partners have you had? Do you have multiple sex partners? Have you ever been diagnosed with or treated for sexually transmitted infection? Have you used contraception in the past? If so, what kind and what was your experience on it? Have you ever received HPV vaccine? Do you do self-breast examinations? Do you breasts become ore painful/tender around your menstrual cycle? Do you experience any urinary symptoms such as urinary incontinence, pressure, or painful intercourse? Do you have adequate financial means for prescription? Do you still suffer from migraines? If so, how often? Do you experience any changes with migraines (worse or better) at or around your menstrual cycle? Do you experience aura with migraines? Are you currently taking any other medications for the medical history you provided? Do you or does anyone in your family have or ever have had blood clots? Stroke? Cardiovascular disease? Have you had any unintentional weight loss or gain? Do you experience any chest pains or pressures or palpitations?
Diagnostic results: Obtain Urine HCG. Pelvic examination, Pap smear (if not done in last 3 years). Std testing: syphilis, chlamydia, and gonorrhea, hiv. Clinical breast examination (obtained on physical exam). Pelvic ultrasound to evaluate bladder prolapse if pt is reporting symptoms.
A .
Primary Diagnoses: Encounter for Generalized Counseling and Advice on Contraception. Z30.0. E.G is a 38y/o, W, F, G5, P5 0 0 6, who presents to the clinic today to “discuss contraceptive options” . E.G is in a new, monogamous relationship with her boyfriend and states that although he has never fathered a child, she is not interested in having more children. Past medical history is significant for migraines, IBS, and exercise-induced asthma. Further information is needed to assess current medical status, medications, as well as past/current history of menstrual cycle: regularity, cycle days, flow etc, and experience with contraception methods in the past.
DDX#1 Fibrocystic Breasts. Upon physical examination, E.G breasts were noted to be soft with fibrocystic changes bilaterally without masses. Most women with fibrocystic changes and without bothersome symptoms do not need treatment, but the doctor might recommend watching the changes closely (American Cancer Society, 2022). Fibrocystic breast disease is the most common benign type of breast disease, diagnosed in millions of women worldwide (Malherbe et al, 2022). Certain hormonal factors underpin the function, evaluation, and treatment of this disease (Malherbe et al, 2022). Current recommendations for mammography screenings suggest beginning at age 50 for average-risk women, unless there is high-risk such as 2 first- or second-degree relatives who developed breast cancer before the age 50 or 3 first- or second-degree relatives who developed breast cancer at any age or had a known gene mutation (Lockwood, 2019).
DDX#2 Prolapsed Bladder. Pelvic Vaginal examination of E.G. revealed 1st degree cystocele . Cystocele, otherwise known as a protrusion of the bladder, occurs when the bladder descends into the vagina (Makajeva et al, 2022). The bladder bulges through the anterior wall of the vagina, with which it is anatomically associated (Makajeva et al, 2022). Cystoceles result from a weakness of the pelvic-floor support system. The main associated risk factors are obesity, increasing age, and parity. They can also occur due to chronically increased intra-abdominal pressure, collagen abnormality, family history of cystocele, and following pelvic surgery. Complaints related to bladder prolapse may be divided into vaginal pressure, urinary symptoms, sexual dysfunction, and, rarely, defecatory symptoms (Makajeva et al, 2022). To aid history taking, a set of questions called the Pelvic Floor Impact Questionnaire (PFIQ) can be used to assess pelvic prolapse related symptoms (Makajeva eta l, 2022). Prolapse consists of 4 stages; stage 0; no prolapse, stage 1; most distal part of prolapse is -1cm (above the level of the hymen), Stage 2 – most distal part of prolapse is >= -1cm but <= +1cm (<=1cm above or below the hymenal plane), Stage 3 – most outside portion of the prolapse >+1cm but <+(total vaginal length -2)cm (beyond the hymen; protrudes no farther than 2cm less than the total vaginal length), and Stage 4 – complete eversion of the vagina; most distal portion of the prolapse >= +(total vaginal length -2) cm (Makajeva et al, 2022). Perineal floor ultrasound scan is used to identify the evulsion of the perineal muscles from the symphysis pubis, which can increase the risk of cystocele development three to four times (Makajeva et al, 2022).
DDX#3. Migraine. E.G. has past medical history of migraines. Further information is needed to assess pattern, frequency, duration, severity and triggers of such migraines and treatments. Migraine is a genetically influenced complex disorder characterized by episodes of moderate-to-severe headache, most often unilateral and generally associated with nausea and increased sensitivity to light and sound (Pescador & De Jesus, 2022). As migraines are more frequent among females, a variety of hormones have been implicated in their pathogenesis; specifically, prior research has repeatedly shown evidence linking estrogen to migraine headaches (Reddy et al, 2021).
1.
E.G is a 38Y/o W, F G5, P5 0 0 6, who presents to the clinic to “discuss contraceptive options”. E.G is in a new relationship with her boyfriend and although he has never fathered a child, E.G states that she is not interested in having more children. Important considerations to discuss with E.G and her boyfriend are if the agree to birth control and if so, to what method; ie; barrier methods, short acting hormonal, long-acting hormonal, sterilization. Birth control methods are designed to prevent conception or interrupt or nullify implantation and growth. Conception can be prevented by hormonally disrupting the menstrual cycle (Oral contraceptive (OC) pills), by physically blocking the passageway (barrier methods or sterilization), or less successfully, by abstinence during fertile periods or withdrawal method. Implantation is impaired via the use of a foreign body (intrauterine device {IUD}) or surgical removal (Salpingectomy or Vasectomy) (Bansode et al, 2022). In addition, E.G. does not have any recent medical work up on file, so we will begin by obtaining pertinent medical history and information such as LMP? Menstruation history? Prior methods of contraception? Obtain a urine HCG, pelvic examination including pap smear, and STI screening for baseline studies. In addition, upon clinical breast examination, E.G has fibrocystic changes bilaterally and will need further information regarding any symptoms she may be experiencing and continued monitoring and assessments. E.G has 1st degree cystocele and further information is needed to assess for symptoms and possible need for imaging versus monitoring.
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