responses.

 

PLEASE RESPOND WITH 1-2 PARAGRAPHS TO EACH POST 

POST 1 

Case Scenario 1:

Complete the chart and answer the case scenario.

Birth Control

How it works/ frequency of usage

% of effectiveness perfect use VS typical use

Combined contraception VS Progestin only method

Contraindicated for patients with/ who are

Pill

Oral contraceptive taken daily

99% (perfect use) vs. 91% typical use

Combined contraception: Contains estrogen and progestin. Progestin-only: Contains only progestin.

History of blood clots, liver disease, breast cancer, smokers over 35

Patch

Transdermal patch changed weekly

99% (perfect use) vs. 91% (typical use)

Combined contraception: Contains estrogen and progestin. Progestin-only: Contains only progestin.

Same as pill plus sensitivity to adhesive

NuvaRing

Vaginal ring replaced monthly

99% (perfect use) vs. 91% (typical use)

Combined contraception: Contains estrogen and progestin. Progestin-only: Not applicable.

Same as the pill plus vaginal yeast infections

Annovera

Vaginal ring used for a year

99% (perfect use) vs. 91% (typical use)

Combined contraception: Contains estrogen and progestin. Progestin-only: Not applicable.

Same as the pill plus vaginal yeast infections

DMPA

Injectable progestin every 3 months

99% (perfect use) vs. 94% (typical use)

Combined contraception: Contains estrogen and progestin. Progestin-only: Contains only progestin.

History of bone density loss, unexplained vaginal bleeding, breast cancer

Implant

Subdermal implant effective for up to 3 years

99% (perfect use) vs. 99% (typical use)

Combined contraception: Contains estrogen and progestin. Progestin-only: Contains only progestin.

History of blood clots, liver disease, breast cancer, smokers over 35

Paragard

Copper IUD effective for up to 10 years

99% (perfect use) vs. 99% (typical use)

Combined contraception: Contains estrogen and progestin. Progestin-only: Not applicable.

Pregnancy, Pelvic inflammatory disease, abnormal uterine bleeding

LNG IUD

Hormonal IUD effective for up to 5 years

99% (perfect use) vs. 99% (typical use)

Combined contraception: Contains estrogen and progestin. Progestin-only: Not applicable.

Pregnancy, Pelvic inflammatory disease, abnormal

Denise, a 19-year-old female presents to the clinic for an annual physical exam.  She is G0P0 and presents with irregular menses only occurring every 3-4months apart within the past 2 years. She is sexually active and only using condoms occasionally. She is not on any other birth control methods. She denies any significant medical or surgical health history and denies any other current health problems.  She has never had a Pap smear or any pelvic exam tests before today. Her pregnancy test is negative, and her vital signs are all WNL.

SOAP Note:

Demographic: 19-year-old female

Subjective:

Chief complaint: 19-year-old patient reports irregular menses occurring every 3-4 months apart within the past 2 years during her annual physical exam. She verbalized being sexually active and only uses condoms occasionally. Denies use of any additional birth control methods. Patient has never had a pelvic exam or PAP smear prior to today’s visit.

Relevant questions regarding the HPI:

– Asking about the nature of her irregular menses.

– Any associated symptoms such as pain or abnormal bleeding.

– Sexual activity details, frequency of condom use.

– Any previous experience with birth control methods.

Medical history

– Ask about any chronic conditions, past surgeries, allergies, medications, family history of reproductive or hormonal disorders, and menstrual history.

Social history

– Ask about lifestyle habits, including smoking, alcohol consumption, drug use, sexual practices, and contraceptive preferences.

Review of Systems:

General: No weight loss, fatigue, or fever was reported.

HEENT: No headaches, vision changes, or ear, nose, or throat symptoms reported.

Lungs: No cough, shortness of breath, or wheezing reported.

Heart: No chest pain, palpitations, or edema reported.

Abdomen: No abdominal pain, nausea, vomiting, or changes in bowel habits reported.

GU: No dysuria, frequency, urgency, or hematuria reported.

GYN: Irregular menstrual cycles reported. No vaginal discharge, itching, or pelvic pain reported.

Musculoskeletal: No joint pain, stiffness, or swelling reported.

Neurological: No numbness, weakness, or changes in sensation reported.

Psychiatric: No mood changes, anxiety, or depression reported.

Objective:

General: Denise appears well-nourished and in no acute distress.

HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light. Tympanic membranes intact, no erythema or drainage noted.

Lungs: Clear to auscultation bilaterally, no wheezes or crackles.

Heart: Regular rate and rhythm, no murmurs, rubs, or gallops.

Abdomen: Soft, non-tender, non-distended. No organomegaly or masses palpated.

GU: External genitalia normal. No lesions or abnormalities noted.

GYN: No cervical motion tenderness. No cervical discharge or masses palpated.

Musculoskeletal: Full range of motion in all extremities. No joint deformities or swelling noted.

Neurological: Cranial nerves II-XII intact. Sensation and motor strength intact bilaterally.

Psychiatric: Denise is cooperative and oriented to person, place, and time. No apparent mood or affect disturbances.

Lab Tests Ordered: Pregnancy test (urine) to confirm negative pregnancy status.

Diagnosis:

Irregular menstrual cycles (ICD-10 code: N92.6)

Differential Diagnosis:

Polycystic ovarian syndrome (ICD-10 code: E28.2)

Thyroid dysfunction (ICD-10 code: E03.9)

Amenorrhea (ICD-10 code: N91.0)

Plan:

Prescribe combined oral contraceptives to regulate menstrual cycles and provide contraception.

Provide patient education on contraceptive use, including proper administration, potential side effects, and the importance of consistent use.

Advise Denise on the importance of regular follow-up visits for monitoring and adjustment of contraceptive therapy if necessary.

Schedule a follow-up appointment in three months to assess treatment efficacy and address any concerns or side effects.

Patient education

Patient should focus on the importance of consistent contraceptive use to prevent unintended pregnancy, understanding the chosen method’s mechanism of action, proper usage instructions, potential side effects, and the importance of regular follow-up visits for monitoring and adjustment if necessary. Additionally, emphasizing the importance of regular cervical cancer screening starting at age 21 should be included in patient education, but it may not be relevant for this visit.

Follow up: 1 month

Health Maintenance

HIV Infection Screening

STD screening

Hypertension in Adults

Prevention of Acquisition of HIV

Anxiety Disorders in Adults

Depression and Suicide Risk

Reference:

Cooper, D. B. (2022, November 24). Oral contraceptive pills. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK430882/

_______________________________________________________________________________________

post 2 

Case Scenario 2

Complete the charts and answer the case scenario. 

2018 USPSTF Guidelines

2020 ACS Guidelines

Age 21-24

Pap test every 3 years (National Cancer Institute, 2020)

No screening (National Cancer Institute, 2020)

1. Age 25-29

Pap test every 3 years (National Cancer Institute, 2020)

HPV test every 5 years (preferred)

HPV/Pap cotest every 5 years (acceptable)

Pap test every 3 years (acceptable) (National Cancer Institute, 2020)

Age 30-65

1. Pap test every 3 years, HPV test every 5 years, or HPV/Pap cotest every

5 years (National Cancer Institute, 2020)

HPV test every 5 years (preferred)

1. HPV/Pap cotest every 5 years (acceptable)

Pap test every 3 years (acceptable) (National Cancer Institute, 2020)

Age 65 and older

No screening if a series 

of prior tests were normal and not at high risk for cervical cancer (National Cancer Institute, 2020)

No screening if a series of prior tests were normal (National Cancer Institute, 2020)

American Cancer Society Recommendations for the Early Detection of Cancer in Average-Risk, Asymptomatic Adults

CANCER SITE

POPULATION

TEST OR PROCEDURE

RECOMMENDATION

SUMMARY

Breast

Women 40-44

breast cancer screening w/ mammogram

option to start annual screening if they wish to do so. (ACS, 2023)

Women 45 – 54

Mammogram

Annually (ACS, 2023)

Women 55+

Mammogram

Q2 years, or can continue annual screening. (ACS, 2023)

Start at age 25

Cervical cancer screening

<25 y/o should not be tested. (ACS, 2023)

25- 65

primary HPV test or

Q5 years (ACS, 2023)

Pap smear

Q3 years (ACS, 2023)

1. 65+

Cervical cancer screening

If regular testing for the past 10 years is normal, we can stop testing. Once testing has stopped, it should not be started again. 

1. For pt with cervical pre-cancer, screening should continue for at least 25 years after dx. (ACS, 2023)
2. Ellen is a 35-year-old female whose latest Pap smear result reports HSIL with positive HPV.  Ellen reports no h/o of STIs or previous abnormal Pap smear results. She had only two previous Pap tests 7 and 14 years ago.  Ellen is G1P0 with a TAB at age 25.  She and her partner are undecided whether they want to have children.  She has been monogamously married to a female partner for the last 5 years, but she considers herself bisexual and has previously engaged in sexual activities with males and females.  Ellen denies any significant medical history or current health problems. Her LMP was 5 days ago and her VS are WNL.  Her BMI is 24.7.  Her pregnancy test is negative.
3. Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note. 

Subjective: 

What other relevant questions should you ask regarding the HPI? 

What other medical history questions should you ask? 

1. What other social history questions should you ask?
2. Objective: 
3. What other point of care testing (POCT) would you perform or order for this patient? Why?
4. Assessment/ Diagnosis: 

What would be an appropriate diagnosis for her? Explain Ellen’s Pap smear results (pathophysiology) and the action(s) that will be taken next to follow up this abnormality, including patient education (explain the procedure to the patient).

Plan: 

What will you prescribe for this patient? Why?

What patient education is important to include for this patient? 

Is there any education or advice you would give to Ellen regarding her current female partner?

What pharmacological and non pharmacological education and advice can you give Ellen to help with her HSIL condition?

Please refer to evidence-based guidelines to support your decision-making.

• Demographic Data 
• 35 y/o F
• Subjective 
• Chief Complaint (CC)
• Pt presented for a review following recent pap smear result, which reported HSIL w/ (+) HPV.
• History of Present Illness (HPI): 

35 y/o F presented to clinic w/ no history of STIs or previous abnormal Pap smears. 2 Pap tests have been conducted about 7 and 14 years ago. Pt is G1P0 w/ a TAB at age 25. Currently, pt has no significant medical history or health problems. Pt’s LMP was 5 days ago.

Allergies: NKA

Medication: Denies

Past History

Medical: 

OB/Gyn: G1P0 w/ TAB at age 25. Previous Pap tests was wnl (7 & 14 years ago)

No other medical history was provided/noted.

Surgical: Denies

Family

No family history was provided but should be questioned due to concerns due to (+) HPV results

Social

Pt is married monogamously to a female partner for 5 years. Identifies as bisexual and has had sexual activities with both males and females. Undecided to childbearing in the future.

Additional questions about smoking, alcohol, and drug use should be asked because it may be a risk factor. 

Immunization

Unknown/Not provided.

Review of Systems (ROS) as appropriate:

Const: Have you recently had any fever/chills?

Head: Have you suffered from any recent headaches or changes in vision?

Resp: Are you experiencing any SOB, pain on inspiration, or wheezing?

CV: Are you experiencing any chest pain, palpitation, claudication, or noticed any leg edema?

Gyn: Are you experiencing any recent abnormal vaginal discharge, bleeding, or pain?

Objective 

Vital Signs

WNL

Weight: xxx lbs

BP: xxx/xx

Pulse: xx bpm

Resp: xx RA

Temp: xx.x F Temporal

Physical Assessment

Gen: AOx4, in no acute distress.

Airway: Airway is patent without obstruction or stridor.

Breath: Bilateral, symmetric breath sounds with normal chest rise and fall.

Circ: 2+ Peripheral pulses, normal capillary refills.

Neuro: Normal reflexes, no sensory deficits.

Cardio: RRR, no murmurs, gallops, or rubs.

Resp: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.

Extremities: No cyanosis, clubbing, or edema.

Assessment (the diagnosis) 

Diff Diagnosis

Cervical Intraepithelial Neoplasia (due to HSIL findings)

Cervical cancer

Final Diagnosis

Abnormal cytological findings in the cervix (ICD 10: Z01.419)

Encounter for gynecological examination (R87.610)

Plan 

Dx Plan

Colposcopy w/ biopsy to assess the extent of cervical dysplasia

HPV DNA typing

Tx Plan: 

No pharmacological treatment is indicated at this time

Observation and repeat Pap and HPV testing in 1 year if colposcopy is negative. 

Pt. Education, including specific medication teaching points 

Medication

None indicated

General measures

Educate pt on the significance of HSIL and (+) HPV results. Explained the importance of follow-up and possible treatment adherence.

Discuss the importance of regular pap smears and HPV testing to monitor for cervical cancer.

Educate pt on HPV transmission and its association with cervical cancer and the sexual partner involved who has not been vaccinated. 

Health maintenance: 

Offer HPV vaccination if pt has not received it. 

Discuss lifestyle changes such as smoking cessation and maintaining a healthy diet. 

Follow up in 1-2 weeks to discuss biopsy results.

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