General: Pleasant, well developed, obese, in no acute distress.
Respiratory: CTA bilaterally, no wheezes, rales, or rhonchi.
Cardiac: RRR, S1 S2 normal with no murmurs, rubs, or gallops.
Breast: Tanner V symmetrical.
Abdomen: Bowel sounds present, abdomen soft, nontender, nondistended, with no hepatosplenomegaly. Exam limited by adipose habitus.
Genitourinary: Pubic hair normal; Tanner V normal female; mucosa pale and pink, no lesions; no lymphadenopathy, discharge, or odor.
CRITICAL THINKING
1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Urine HCG___HIV testing___STI screening___Pap smear___Urine dipstick
2 Why is it important to ask Genny what she feels her boyfriend would want if she were pregnant?
3 What additional questions should Genny be asked?
4 If Genny is pregnant today, what are her options?
5 Should contraception be prescribed today?
6 What health education should be provided to this patient?
7 Are there technologies available to assist Genny in managing or understanding her menstruation?
Case 5.5 Birth Control Decision‐Making
By Jessica Chan, MSN, APRN, PPCNP‐BC
SUBJECTIVE
Lauren is a 17‐year‐old female who presents alone to the primary care office to discuss birth control options. She has been in a relationship with her boyfriend for 6 months and is currently sexually active with only him. She has a history of 1 partner prior to her current boyfriend. She reports using condoms always and never having unprotected intercourse. She has not discussed this with her mother yet, but does think she could be open about it. She has not had testing in the past for sexually transmitted infections (STIs), but would be interested and denies symptoms such as abnormal vaginal discharge, dysuria, pelvic pain, or any new rashes or lesions. She is due for her menses in 3 days. She generally has cramps the day before and the first day of her menses, and takes ibuprofen with good effect.
Past medical history: Lauren has a history of eczema and seasonal allergies.
Family history: Lauren’s biological mother has a history of dysmenorrhea.
Social history: Lauren lives at home with her mother, father, and younger brother. She is in the 12th grade and plays tennis for fun. She reports having many good friends and denies substance use.
Medications: Lauren’s medications include cetirizine (Zyrtec) 10 mg daily during allergy season and occasional triamcinolone cream for her eczema.
Allergies: NKDA.
OBJECTIVE
General: Well appearing, no acute distress
Vital signs: Weight: 145 lbs; height: 62 inches; BMI: 26.5; HR: 72; B/P: 116/74.
Cardiovascular: Regular rate and rhythm. S1/S2 normal.
Respiratory: Lungs clear to auscultation bilaterally.
Breast: Tanner V breast development noted. Not palpated at time of visit; at last annual physical exam had normal breast exam with no masses.
Gastrointestinal: Bowel sounds normoactive in all four quadrants. Soft, nontender, nondistended, with no hepatosplenomegaly.
Genitourinary: External exam with Tanner V pubic hair development noted and no lesions present.
CRITICAL THINKING
1 Given the information provided, what other questions would you ask?
2 What diagnostic or screening tests would you consider running on this patient?___Urine pregnancy test___Beta pregnancy test (serum hCG level)___Urine gonorrhea and chlamydia (GC/CT)___Serum HIV immunoassay and RT‐PCR (viral load)___Serum RPR (reactive plasma reagin) or VDRL (Venereal Disease Research laboratory) testing for syphilis___Pelvic exam with wet mount___Pap smear___Complete blood count (CBC)___Lipid panel (baseline cholesterol screening)
3 What are the concerns at this point?
4 What is the diagnosis at this point?
5 What types of contraceptives should be considered for Lauren?
6 How would each contraceptive option be initiated?
7 What are some common contraindications to contraceptives?
8 How should Lauren be counseled about side effects?
9 What are the plans for referral and follow‐up care?
10 What other education should Lauren be provided with related to reproductive health?
11 If the patient chooses not to discuss her choice to seek out birth control options with her mother, how would you proceed?
12 Are there any standardized guidelines that should be used to treat this case? If so, what are they?
Case 5.6 Vaginal Discharge
By Betsy Gaffney, MSN, APRN, FNP‐BC
SUBJECTIVE
Nora, an 18‐year‐old college student known to this family practice office, presents with a complaint of “some spotting since my last period and a vaginal discharge.” Nora is home on a college break and states “I’m afraid I have an STD.” She relates that she has “been healthy” while at school “except for this problem” and that she “did not feel comfortable going to the university health center.” She denies any urinary burning or frequency. She denies any abdominal pain or pain with sex.
Past medical/surgical history: Negative with exception of tonsillectomy, age 7.
Medications: None.
Allergies: No known allergies.
Menstrual history: Menarche age 10 with regular 28‐day cycle with 3–5 days of bleeding. Last menses 3 weeks ago with intermenstrual spotting 2 times since then.
Sexual history (obtained using the CDC’s “5 P” approach):
Partners: Nora’s first sexual encounter was at age 16. She has had 4 encounters in the past 2 years with 2 different partners, with 2 encounters in the last 2 months.
Prevention of pregnancy: Nora was prescribed a triphasic oral contraceptive at age 16 but says “I stopped taking it after a few months and haven’t been on any since.” Her partners “use condoms once in a while.”
Prevention of STIs: Limited to inconsistent condom use.
Practices: Nora describes her encounters as limited to vaginal intercourse and “oral sex once in a while.” She denies anal sex.
Past history of STIs is negative.
OBJECTIVE