Margaret\’s examination finds her height 5\’5\”, weight 172 lb (up 10 lb
University:
SOUTH UNIVERSITY
Margaret\’s examination finds her height 5\’5\”, weight 172 lb (up 10 lb
Paper Instructions
Margaret is a 40-year-old white female in for her annual examination. She states she has been under increased stress in her life for the past few months. She and her husband are currently separated and considering divorce. Her teenaged sons are acting out and she is working extra hours to make ends meet. Secondary to the increased stress she has started smoking again, \”about a pack per day\” and states \”I know that I am not eating right.
Margaret has been on the \”pill\” for almost 20 years and has always liked the method. She states the she has heard that smoking and taking the pill are not good, and she is worried about that. \”I really do not need birth control since I am separated but just in case I probably need something.\” She states that she has been in a mutually monogamous relationship (as far as she knows) since her marriage 18 years ago. She denies a new partner since her separation.
Menarche was at 11 years, her cycles when on the pill are regular and very light. Her menstrual period should start tomorrow as she just finished her active pills. She denies a personal history of abnormal Pap smears, gynecological issues, hypertension (HTN), or diabetes. She is G2P2002, and her pregnancies were full term and uncomplicated at ages 24 and 26.
Family history is significant for both parents with HTN and mom has type 2 diabetes. Her paternal grandfather died at age 64 years from type 2 diabetes, HTN, and coronary artery disease. Her other grandparents died in their late 70s early 80s and she is unaware of any medical issues.
Assessment
Margaret\’s examination finds her height 5\’5\”, weight 172 lb (up 10 lb. from last year), current body mass index (BMI 28.6), and blood pressure (BP) 148/88. Head, eyes, ears, nose, and throat (HEENT) are grossly within normal limits (WNL). No thyromegaly or lymphadenopathy.
Heart rate is regular and rhythm is without murmurs, thrills, or rubs. Lungs are clear to auscultation in all lobes. Breasts are without masses, nipple discharge, asymmetry, or lymphadenopathy; self breast examination techniques and frequency reviewed during examination. Abdomen is soft, nontender, with no masses or hepatosplenomegaly; bowel sounds present in all four quadrants.
Pelvic examination reveals normal vulva and negative Bartholin\’s and Skene\’s glands; vagina is pink, rugated, with minimal white nonodorous discharge; cervix is pink, multiparous os. Pap smear collected during speculum examination was normal. Bimanual examination reveals a retoverted, firm, mobile, nonenlarged, nontender uterus with negative cervical motion tenderness; adnexa nontender; and ovaries palpable bilaterally, mobile, without masses. Lower extremities were without edema or varicosities.
- What options are appropriate for this patient?
- What contraceptive options are contraindicated?
- What type of patient education is indicated?
- Given that she has a normal pelvic exam, does that change would that influence your decision?
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Sample Answer
Pharm Week 8
The contraceptive options appropriate for Margaret include non-hormonal methods such as the Copper intrauterine device. She can also use mechanical barriers such as condoms or permanent contraception through tubal ligation (Britton et al., 2020). These methods do not contain hormones, which may affect the patient’s blood pressure and weight. The Copper intrauterine device would be the most appropriate since it is long-term and have high efficacy.
Contraceptive options contraindicated for Margaret include hormonal contraceptives due to associated side effects of weight gain, depressed mood, hypertension, and arterial and venous thrombosis (Curtis et al., 2016). The hormonal contraceptives include Progestin-only oral pills (POPs), combined oral contraceptives (COCs), Contraceptive vaginal ring, Combination patch contraceptive, and Injectable Depo-Provera.
Besides, hormone-releasing intrauterine devices such as Mirena are contraindicated for this patient. Contraindications for hormonal contraceptives containing estrogen include History of smoking more than g ≥15 cigarettes/day, multiple risk factors for cardiovascular disease, hypertension with systolic BP 140–159, or diastolic pressure 90–99 mmHg, and obesity (Curtis et al., 2016). The patient in the case has a high BP of 148/88, a high BMI of 28.6, an active smoker, and has multiple risk factors for cardiovascular diseases.
Patient education for Margaret should center on lifestyle modification on diet, physical activity, and smoking. She should be recommended to engage in regular physical exercises to promote weight loss and lower BP. Besides, she should be advised to have a low sodium and caloric diet to lower BP and promote weight loss. The patient should be advised to stop taking contraceptive pills and be educated on their side effects (Britton et al., 2020).
Furthermore, she should be advised to use a barrier method if she has multiple sexual partners to prevent STIs (Britton et al., 2020). The patient’s normal pelvic exam influences the decision to have the Copper intrauterine device since there are no signs of conditions that would rule out IUD insertion.
References
- Britton, L. E., Alspaugh, A., Greene, M. Z., & McLemore, M. R. (2020). CE An Evidence-Based Update on Contraception. The American journal of nursing, 120(2), 22–33. https //doi.org/10.1097/01.NAJ.0000654304.29632.a7
- Curtis, K. M., Tepper, N. K., Jatlaoui, T. C., Berry-Bibee, E., Horton, L. G., Zapata, L. B., … & Whiteman, M. K. (2016). US Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR. Recommendations and reports Morbidity and mortality weekly report. Recommendations and reports, 65(3), 1-103.
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