Case Study Discussion 1

Case Study Discussion 1

Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your clinic today to discuss contraceptive options.  She states that she is not interested in having more children but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs.  She has no known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. 

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.  

· Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 Pulse 68  

· HEENT (head, ears, eyes, nose, throat):  wnl (within normal limit)

· Neck: supple without adenopathy  

· Lungs/CV (cardiovascular): wnl  

· Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge  

· Abd (abdomen): soft, +BS (positive bowel sound), no tenderness  

· VVBSU (Vulvar vaginal bartholin skene’s uretha): wnl, except 1st degree cystocele  

· Cervix: firm, smooth, parous, without CMT (cervical motion tenderness)

· Uterus: RV (retroverted), mobile, non-tender, approximately 10 cm,  

· Adnexa: without masses or tenderness  

Based on the case study scenario provided, complete a comprehensive well-woman exam and critically analyze to focus attention on the diagnostic tests (include explanation of the tests you might recommend).

Include your differential diagnosis. Be specific and provide examples. Use your Learning Resources and/or evidence from literature to support your explanations.

Some questions to answer in your post:Case Study Discussion

1. What other information do you need?

2. What has she used in the past?  Why did she stop a method?  How many partners in past 12 months?  

3. What are her current cycles like?  

4. When was her last gyn exam and what were the results of the tests?   

5. Are her migraines with or without auras?  

6. What method has she considered. 

7. What are you next steps/considerations?

8. What teaching should you do?

9. What methods are appropriate for Elaine?

The patient in the case scenario is a 38-year old female with multiple pregnancies that comes into the clinic, possibly interested in learning about contraceptive methods. She acknowledges she is not interested in having any more children but may feel obligated to have another child because of the partner’s wish.

She has been pregnant five times and has six children, which means she has at least one set of multiple births. She has some health issues, but they seem to be well controlled since she has not verbalized any problems. She denies smoking, alcohol, or illicit drug use. She has never been hospitalized except when she was pregnant.

Missing Elements of the Health History

(PMHx, Social Hx, Family Hx, OB/GYN/Sexual Hx)

There are several gaps in the case study that haven’t been disclosed which would offer valuable information on the best course of action for this patient. First, she has been diagnosed with exercise-induced asthma, migraines, and IBS. We are not told how often she has asthma attacks, what are her triggers, when was her last flare-up, and does she monitor her symptoms using a peak flow meter. How does the migraine headaches influence her life, are they associated with aura’s, does anyone in her family suffer from migraines, and how often does she get the headaches?

Is the IBS stress-related or caused when she eats a certain food, any rectal bleeding, weight loss, or persistent abdominal pain? Besides taking Vitamin C supplements, the vignette does not elaborate if she takes medication for her other ailments, how often she takes them and does the therapy control her symptoms.  What is the purpose of taking the supplement? Missing information in her social history includes her career status, the number of people who live in her home, does she live with her partner, sexual orientation, financial or emotional stressors, level of education, feelings of depression, dietary habits, exercise regime, and things she enjoys doing with her free time.

Diving deeper into her thoughts regarding her partner’s desire to have children- still, her not wanting more kids is the reason why an intimate partner abuse assessment should be conducted. Asking questions such as has your partner ever pressured you to have more children, does your partner withhold financial resources unless you agree to have more children, does your partner ever threatened to leave if you don’t agree to have more children, or does your partner refuse to use contraception during intercourse (WCSAP, 2020)?.

The case study fails to mention if her parents are still living and what medical problems they may have. Family history is important hence allowing the practitioners to begin screening for certain health conditions that have a strong genetic component. Does anyone in her family have a history of breast cancer, BRCA 1 or 2 gene mutation, cervical, ovarian, or endometrial cancer? Has she received an HPV, yearly flu, or updated Tdap vaccine?. Although her vitals are unremarkable, the clinician should also take this time to screen for hypertension, hyperlipidemia, diabetes, and check her thyroid function. 

It also doesn’t mention if her children have health problems as managing a sick child is an added stressor. According to Piran et al., 2017), children with chronic diseases impose caregiver burden affecting their physical, psychosocial, and financial stability.  

The case study neglected to discuss her OB/GYN and sexual history with questions regarding her menstrual cycle (pattern, flow, duration, pain), age at menarche, last pap smear/HPV testing with results, monthly self-breast exams, type of delivery (vaginal or c-section), number of sexual partners within the last 12 months, type of sexual intercourse (vaginal, oral, anal), STI exposure/treatment, vaginal discharge/odor, pain with intercourse, consistency with using condoms or other barrier methods during sex, and what type of birth control has she used or considering.

Since she is a multi-parous female, has she noticed difficulties with voiding or leakage of urine when she laughs, sneezes, or coughs. Any other changes to urinary functions like frequency, urgency, night wetting, dribbling, difficulty initiating stream, leakage with laughing, coughing, or sneezing.

Birth Control Alternatives and Education

            The next phase for the clinician to consider is going over the different birth control options that would fit best with the patient’s lifestyle. The patient is a busy mom with six children; therefore, I believe contraceptive pills won’t be the best therapy to advise.  She could forget to take the pill as instructed, reducing the efficacy of the medication.

The pill is only effective when the person takes it judiciously, and nine out of ten women have unintended pregnancy every year with the oral contraceptives (Cleveland Clinic, 2020).  Also, if she is in an abusive relationship, her partner could discard the medication as a means to control her reproductive autonomy.

As her clinician, I would counsel this patient on IUD, Paragard, or Nexplanon placement. IUD’s and Paragard are inserted into the uterus with a little string dangling outside the cervix within the vagina (Medline Plus, 2020). IUD’s is a reversible minimally invasive hormone impregnated device that prevents conception for five to seven years.

Paragard is a non-hormonal device that’s wrapped in copper wire to prevent pregnancy up to 12 years (Planned Parenthood, 2020). Nexplanon is an instrument that’s implanted underneath the skin, usually in the inner forearm, preventing pregnancy for up to five years.

            All these methods help regulate menstrual flow, menstrual cramps, or stops periods altogether and are highly effective, not requiring any special maintenance.  These mediums are considered a fail-proof tactic because there is almost no way to mess it up.

The patient would no longer have to worry about her partner initiating or choosing which barrier method but can feel as she is in control of her reproductive health.  I would educate this patient that this does not prevent an STI/HIV, so refraining from having multiple partners is best or use additional protection such as condoms.

Some other teaching points necessary to inform the patient is irregular bleeding during the first few months of placement, the small risk for ectopic pregnancy, spontaneous device expulsion, and ovarian cysts that usually resolve on their own (Medline Plus, 2020).

 I would empower this patient by letting her know she is not obligated to have more children just to please her partner. Her partner can still be a father to her children even though they are not biologically linked. If a form of IPV is suspected, a referral to social work to help the women decide on the next course of action for her family.   

Differential Diagnoses

           Considering the patient’s history and physical examination, my top three differential diagnoses are prolapsed bladder (cystocele), stress incontinence, UTI. Upon her physical examination, it noted that she has a first-degree cystocele, which is indicative of pelvic floor weakening.  According to the NIDDK (2014), the supportive tissue between the bladder and vagina stretches, displacing the bladder from its anatomical position into the vagina. A common occurrence in women with multiple vaginal births as extra weight on the pelvic floor can cause the muscles to weaken.

Other factors that can weaken the pelvic floor include constipation, repetitive straining for bowel movements, heavy lifting, obesity, and chronic coughing. Cystoceles have three stages, with the mild form being treated with Kegel exercise or vaginal pessary. Kegel exercises are repetitive contracting and relaxing of pelvic muscles to increase tone to hold organs in place.

Kegel exercises are easy to do with no special equipment needed. A vaginal pessary is a small silicone device placed into the vaginal wall as a structural support mechanism preventing further collapse of the pelvic organ, which often requires adjustments for women’s comfort (InformedHealth.org, 2018).

             Stress incontinence is involuntary leakage of urine due to increase pressure on the pelvic wall.  According to Schuiling and Likis (2017), urinary incontinence is very common among women and can occur at any age.  Pregnancy and childbirth have long been associated as factors for urinary incontinence and pelvic floor dysfunction. The bulging of the bladder into other structures causes decrease bladder sphincter tone or urethra hypermobility resulting in incontinence (National Association for Continence, 2018).  Treatment is the same as mild cystocele with strengthening pelvic floor muscles, weight loss, bladder training, and surgery.

           Urinary tract infections (UTI) can result from an obstruction of urinary flow. Inadequate emptying of the bladder due to the bladder prolapse narrows the urethral opening. The retention of urine is a breeding ground for bacteria growth, ultimately developing a urinary tract infection. Although this manifestation is more common with advanced cystocele, one cannot rule UTI out as they share similar clinical presentations.

A diagnosis is made by conducting a bladder ultrasound with post-void residual (PVR) and a UA with culture/sensitivity.  In the study conducted by Töz et al. (2015), recurrent UTI was not associated with pelvic organ prolapse, but they did cite a PVR greater than 50ml is a significant risk factor for linking the two. Women’s health implores a holistic approach to care; hence the patient in the case study needed several topics to be addressed, thereby achieving the goal to provide high-quality medical services to all.