Title: Contraception

Student’s Name:

Professor’s Name:

Date:

Diseased information:

Signs: E.G

Years: 38-year-old

Gender: Female

S.

CC (chief complaint):

“I am not interested in having more children?but my new husband has never been a father.”

HPI:

The patient wants some advice concerning contraception options. She was married before and for this time she does not want to give birth again. The patient has worries since her new husband has never fathered a child.

Current Medications:

The patient has a medical history of migraines, exercise-induced asthma, and IBS. She is currently under vitamin C medication.

PMHx:

Allergies:

No drug allergy

Acute diseases/Main harm:

Have migraines, exercise-induced asthma, and IBS

Surgeries/hospitalizations:

Tonsils surgery when young

Hospitalization during childbirth

Immunization

The patient has undergone all immunizations Social & Substance Hx:

The patient has never been under the influence of? recreational drugs, alcohol, and tobacco. Her mother and dad are alive. She has a sister and a brother who lives with their parents.

Family Hx:

The mother of the patient is alive suffering from fibromyalgia and osteopenia. Her dad is also alive suffering from skin cancer which has affected the basal cells. The patient maternal grandmother and grandfather are alive and suffer from dementia and COPD respectively. The patient both parental grandparents died as a result of an automobile accident. Her brother and sister are alive with no medical complications.

Surgical Hx:

Tonsils surgery when young

Mental Hx:

No anxiety, no depression

No history of suicidal or harm practices

Violence Hx:

No history of security concerns whether at home, personal, community, or sexual. She feels secure at any place.

Reproductive Hx:

Has given birth before

Not pregnant

Review of Systems:

General:

Lacks weight reduction, chills, high temperature, fatigue, or fragility

Heent:

Eyes: Absence of blurred vision, sight loss, yellow sclera, or double sight. Ears, Throat, Nose: Absence of hearing loss, sore throat, sneezing, runny nose, and congestion.

Tegument:

Absence of itching or rashes

CV:

Absence of chest pressure, chest pain, or discomfort, absence of edema or palpitations

Respiration:

Absence of cough, shortness of breath, or sputum

GIT:

Absence of nausea, anorexia, diarrhea, and vomiting, presents abdominal discomfort

Genital infection:

Absence of pain when urinating, No improved frequency

Neurological:

Lacks dizziness, headache, ataxia, syncope, tingling, numbness, or paralysis

+IBS

Muscles and Skeleton:

Absence of back pain, muscle hurt, stiffness, and joint pain.

Hematological:

Absence of bleeding, anemia, and bruising

Lymphs:

Absence of history of splenectomy, absence of enlarged nodes

Psychiatry comments:

Absence of history of anxiety and depression

Endocrinological:

Absence of reports of heat intolerance, cold and sweating, absence of polydipsia and polyuria

Reproductive:

Has given birth before

Allergy:

Absence of history of hives, rhinitis, and eczema, has a history of Asthma

O.

Weight; 148kgs

Height; 5’ 7”

BMI; 23.1

BP; 118/72

P; 68

General visual aspect

The diseased person looks better, groomed, and no distress. She came alone in the clinic and there are no symptoms of fear or abuse.

Neck:

Supple with no adenopathy?

CV/ Lungs:

The lungs have no complications

Breast:

Fibrocystic changes bilaterally, soft, ?with no masses, discharge? , or dimpling

Abdominal:

Soft, no tenderness, +BS?

VVBSU:

Whole except?1st-degree cystocele?

Cervix:

Smooth, Firm, parous, with no CMT?

Uterus:

Mobile, ?RV, non-tender, ?size of 10 cm

Adnexa:

It has no tenderness?or masses

Neurological

Absence of local researches and normal speech

Psychiatrical findings

Lack of anxiety or depression, no insomnia

Diagnostic results:

Blood pressure test- 118/72

Irritable bowel syndrome test- +IBS

A .

Overweight (L02.32). The patient is overweight, and it is evident from a BMI of 32.1

IBS (J02.1). The patient is positive for IBS, and it is evident from abdominal pains and changes in bowel movement.

Fibrocystic breast disease (B30.2), the patient is suffering from fibrocystic breast disease. It is a condition where women experience painful lumps in their breasts.

P.

The plan for treatment includes the following. The patient is to undergo an MRI test to check on the changes in the breast (Vanel & McNamara, 2018). I will prescribe pain relievers ibuprofen and acetaminophen be taken one tablet thrice a day to relieve any discomfort and pain. The dose will be taken for one week. I advise the patient to wear a supportive and fitting bra to reduce breast tenderness and pain. The patient is advised to reduce the intake of caffeine, eat a low-fat diet, and take supplements of essential fatty acids to reduce fibrocystic breast disease symptoms.

To reduce IBS, I recommend the patient to take magnesium hydroxide and Pepto-Bismol (Brewer & Berriedale-Johnson, 2016). Avoid intake of vegetables like Brussels sprouts, cabbage, broccoli, and cauliflower, legumes like beans that increase gas. She should also avoid fried or fatty foods as well as caffeine and soda.

The most effective contraception is the vaginal ring or the NuvaRing. It will have effects because it is not affected by body weight. It is because our patient is overweight with a BMI of 32.1. It has 120 mcg etonogestrel and 15 milligrams of EE. It exposes women to fewer estrogen amounts with proper and stable serum amounts. It gives higher levels of hormones in overweight women compared to oral contraception since they are directly absorbed into the vagina mucus and do not undergo liver metabolism.

The patient should avoid eating junk foods and embrace eating home-cooked foods to reduce her weight. Consume small portions of food at intervals. Eat food only when hungry to prevent overeating. Consume foods rich in fiber since fiber gives a feeling of satiety (Cho & Almeida, 2019). The patient should be physically active by having physical exercises once per day. Limit consumption of calorie intake that results in overweight.

References

Brewer, S., & Berriedale-Johnson, M. (2016). I.B.S.: Reduce pain and improve digestion the natural way (Eat to beat). HarperCollins UK.

Cho, S., & Almeida, N. (2019). Dietary fiber and health. CRC Press.

Vanel, D., & McNamara, M. T. (2018). MRI of the body. Springer Science & Business Media.