What options are appropriate for this patient? What contraceptive options are contraindicated?
Discussion 1: 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. 1. What options are appropriate for this patient? 2. What contraceptive options are contraindicated? 3. What type of patient education is indicated? 4. Given that she has a normal pelvic exam, does that change would that influence your decision? Rubrics Quality of Initial posting- The information provided is accurate, providing an in-depth, well thought-out understanding of the topic(s) covered. An in-depth understanding provides an analysis of the information, synthesizing what is learned from the course/assigned readings. Writing Mechanics- Minor to no errors exist in grammar, mechanics, or spelling in both the initial post and comments to others. Formatting of citations and references is correct. If required for the assignment, utilizes sources to support work for both the initial post and the comments to other students. Sources include course and text readings as well as outside sources (when relevant) that are academic and authoritative (e.g., journal articles, other text books, .gov Web sites, professional organization Web sites, cases, statutes, or administrative rules).
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