Brandi Malsy
October 21, 2014
Case Study # 3
WOMEN'S CASE STUDY
Use the following template to complete your answers to this case study and
resubmit via tigermail to Dr. Wilder (wildebf@auburn.edu) on or before the due
date. Remember that you will lose 20% of your grade for every day it is late.
SCENARIO
Sue Lang is a 26-year old Caucasian female who presents today (10/10/14) for an
annual pelvic exam. She is requesting a method of birth control. Sue has used oral
contraceptives (OC) in the past and became pregnant while taking them. She does not
particularly want to use OCs again.
TENTATIVE DIAGNOSES
Based on the information provided so far, listed are 2 potential diagnoses with
rationale? Would you add any other diagnoses based on the information above?
Diagnosis
Annual pelvic exam
Family planning
Other
Rationale
Well exam. When reviewing this case, keep in mind
that the gynecology well exam may be the only health
maintenance visit for a well female.
Sue wants to begin birth control. Based on her past
experience with OCs she will need a presentation of
various types of family planning.
With the information that is given thus far, I would not
add any more diagnoses at this time
HISTORY
1. List below are the significant questions and answers asked of Sue during this visit?
Highlight significant findings. List any other questions you would like to include in her
history.
Requested Data
Allergies
Current Medications
Childhood diseases
/immunizations
Surgery
Past medical history/
Data Answer
Sulfa
Carbamazine (Tegretol) 200 mg BID, 400 mg HS.
Ibuprofen (Advil) PRN for H/A.
Vitamins.
Chicken pox. All childhood immunizations, last
measles shot at 12 y/o.
PE tubes, age 3.
Elective abortion, age 17.
No transfusions. Hospitalized for vaginal birth 2004,
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hospitalizations/fractures/
injuries/accidents
Adult illness
OB/GYN history
OB/GYN history (cont.)
Appetite
24-hour diet recall
Sleeping
Sexuality
Social history
Family history
Work/finances
Relationship with
husband/children
2007, 2010: MVA, concussion. Takes Tegretol for
seizures that occurred as a result of the accident.
Depression, 2006. Resolved with counseling and no
medications. Gestational diabetes during
pregnancies, controlled by diet.
1999; MVA workup.
Menarche: Age 12, periods usually last 5-6 days,
cycles of approx. 30 days, moderate flow, no
cramping.
LNMP: 9/28/12 normal, skipped one cycle; anxious
about contraception.
Last pelvic: 10/2011.
Mammogram: never.
GPA: G4P3A1.
Contraception: Uses condoms when they think it is
necessary. No other contraception for 2 years.
Small appetite, junk food. Decreased time to eat.
B: Coffee.
L: Mountain Dew, ham sandwich.
D: Fast food: Hamburger, fries, soda, 1 beer after.
5 hours per night. Usually tired.
Relationship with husband strained. Husband does
not mind the idea of another child. She is not
interested in having another child. This has
decreased her sexual interest.
Smoking: Smokes about 2 ppd x 10 yrs.
Alcohol: Approximately 1beer/day (12 oz.)/6 pack/wk.
Recreational drugs: Rare marijuana use.
Exercise: Sporadic.
Social organizations: None
Mother: 49, perimenopausal, hormone therapy.
Father: 48, HTN.
Brother: 28, Good health, smokes.
Husband: 28, well.
Daughters: 8, 2, good health.
Son: 5, good health.
Both Sue and her husband are employed full-time as
factory workers. Her husband works first shift at a
book bindery. She works first shift at a gasket
assembly. Her husband carries the insurance for the
family, but no dental insurance.
Argues frequently with husband about money,
children, household chores, and sexual habits.
Having intercourse approx. 2x/wk. Good relationship
with daughters. Frustrated by trying to meet their
needs and work full time.
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Relationship with family
Losses in life
What do you do when you are
stressed? How do you manage
stress? Medications for stress?
Do you ever think about hurting
yourself?
Do you ever think about leaving
your husband?
Where do you see yourself in
10 years?
What are your thoughts on a
birth control method?
Sue's mother and siblings live approximately 250
miles away. Parents divorced when she was very
young. Does not see family except at holidays. Her
husband's family is located nearby, and they see
them approximately 2-3x/month.
Concerned about loss of free time and relationship
with husband. Felt similar to this when started
Tegretol several years ago.
Sometimes, all I want to do is cry and I find myself
yelling at the kids. My husband does not understand.
Smoke, talk on phone, have a beer. Have never
taken medications for stress.
No.
Yes, but have never gone any farther than thinking
about it.
Here, alone with my children
I do not want to become pregnant. My husband does
not seem to care. I don't want to use anything I may
get pregnant on. I have heard good things about the
shot and would consider that.
2. Below is the ROS, highlight any abnormal findings. And any other symptoms you felt
needed to be reviewed for this visit.
SYSTEM REVIEWED
General
Abdomen
Gynecology/GU
Endocrine
Neurological
Other systems to be reviewed for this
patient?
DATA ANSWER
Feels healthy but tired most of the time.
Denies problems with constipation,
diarrhea, or heartburn.
Denies abdominal pain or tenderness.
Denies vaginal discharge, odor, or itching.
Denies breast tenderness or discharge.
Denies pain on intercourse. Also denies
symptoms of UTI.
Denies dysphagia, urinary frequency,
thirst, poor healing of skin lesions, loss of
weight.
Denies frequent H/A, seizures, confusion
or other problems.
Psychiatric- due to appearing to be
depressed and unhappy in her current
situation.
Respiratory- due to Sue being a smoker.
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PHYSICAL ASSEMENT
Below is the PE, highlight any significant findings and list any other assessment data
you would like to include.
SYSTEM
Vital signs
FINDINGS
B/P: 130/72, P: 78, R:
22, T: 982
Height and weight
General appearance/skin
HEENT
RATIONALE
Vital signs necessary to
determine BP, HR for
decision on what medication
to choose.
Height and weight is needed
to determine BMI
Appears thin and
stated age. Skin pale,
warm, and dry.
Yellowing of skin
around nail beds,
unclean nails.
Bruises, jaundice,
lesions, rash?
Clubbing or
cyanosis?
Can indicate problems with
other body systems such as
the liver or respiratory
system
General appearanceIs Sue dressed
appropriately? Does
she appear well
nourished? Is she
alert and oriented?
Affect?
No thyromegaly.
Can indicate how Sue views
importance of her
appearance. Affect can
indicate whether or not Sue
seems to be depressed.
Normocephalic? Hair
distribution?
PERRLA? Sclera?
Conjunctiva? EOMs
intact? TMs and
canals clear?
Oropharynx? Mucous
membranes?
Dentition? Nasal
turbinates? Sinus
tenderness?
Adenopathy?
A full system assessment
should be completed.
Abnormalities can indicate
infections, malignancies,
and individual fluid status.
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Tenderness? JVD?
Lungs
CTA
Heart
S1S2 normal, no
murmur.
Chest wall
abnormalities?
Rhythm? Rate?
Central or peripheral
cyanosis?
Soft, equal, no masses
or nipple discharge.
Bilateral fibrocystic
changes. Does not do
BSE.
A full cardiovascular
assessment should be
completed as this is
important for medication
selection.
Dimpling present?
Axillary or
supraclavicular
adenopathy? Pain?
As for adenopathy,
malignancies are associated
with firmness, increased
quantity, and adherences to
each other and the chest
wall.
Breasts
Abdomen
BS +, soft without
masses, no LA, no
HSM.
CVA tenderness?
Pelvic
Neurological
Extremities
Hormonal changes can
cause fibrocystic changes.
Sue should do BSE monthly.
If abnormal findings are
found on exam, could
indicate malignancy.
Could indicate presence of
kidney infection.
Uterus: small AV,
normal size and shape.
Cervix: Parous, round,
no lesions, no CMT.
Discharge: WNL.
Adnexa: Negative.
Normal vulva, rectal
deferred.
Alert, moving
frequently, poor eye
contact. Screening
neuro:
strength/sensation
intact, reflexes 2+.
No edema.
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Other assessment?
Psychiatric? Is Sue
anxious?
Cooperative? Calm?
Sue has poor eye contact
and appears depressed.
DIFFERENTIAL DIAGNOSES
Identify the significant positive or negative data to support or refute each differential
diagnoses.
DIAGNOSIS
Family planning
Altered health maintenance
Poor dietary habits
Altered family processes
POSITIVE DATA
Sue is a 26 y/o female with
3 children. She has had an
abortion in the past and
currently does not want any
more children. She became
pregnant using OCs in the
past. Only uses condoms
when she and her husband
think it is necessary, but
uses no other method of
contraception x 2 years.
Sue smokes, drinks
alcohol, smokes marijuana,
does not exercise regularly,
appear pale and thin, has
poor eating habits,
yellowing of skin and nails,
and appears unkept due to
unclean nails. Sue’s
husband carries the
insurance for the family, but
has no dental coverage.
Sue has a small appetite
which mainly consists of
junk food, decreased time
to eat, diet high in caffeine,
fat, and sugar.
B: Coffee
L: Mountain Dew, ham
sandwich
D: Fast food: hamburger,
fries, soda, and one beer
after.
Sue and her husband do
not have a clear agreement
on the decision of whether
or not to have another child:
Sue does not want any
NEGATIVE DATA
Sue smokes tobacco which
is a contraindication with
most OC use. Sue’s
husband doesn’t seem to
care if they have more
children or not.
none
none
Sue has intercourse
approximately twice weekly.
Sue has a good relationship
with her daughters. Her
husband’s family lives
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Depression
Hypothyroid
Anemia
more children and her
husband doesn’t care
whether or not if they do or
do not have another child.
Sue’s relationship with her
husband is strained. They
argue a lot regarding
children, money, household
chores, and sexual habits,
and are both frustrated
trying to meet the needs of
their family and work a fulltime job.
Sue does not see her family
as often as she sees her
husband’s family. Sue’s
mother and siblings live
approximately 250 miles
away and only sees them
during the holidays. Her
parents divorced when she
was very young.
Sue is tired all the time,
decreased sexual interest,
and cries a lot. States she
finds herself yelling at her
kids. States her husband
“doesn’t understand”
Concerned about loss of
free time and relationship
with her husband. Poor eye
contact during examination
with provider.
Sue is tired all the time and
has decreased sexual
interest.
Sue complains of being
tired all the time, appears
thing and pale, and has
poor dietary intake.
nearby and they see them
approximately 2-3 times
monthly.
Sue works a full-time job
and takes care of her
responsibilities. Sue has a
good relationship with her
daughters. Sue has
intercourse with her
husband twice a week.
Does not exhibit weight
gain, cold intolerances,
hypersomnia, hair loss,
constipation, nausea,
memory deficits, irregular
menses, or muscle
weakness or cramping
during the physical
examination.
No complaints of heavy
bleeding during menses.
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Other differential dxs?
Fatigue
Sue works a full-time job
and takes care of three
children. States she is tired
all the time, has a
decreased appetite, poor
dietary intake, and
decreased sexual interest.
DIAGNOSTIC TESTS
Below is a list of diagnostic tests obtained on Sue with the results. Provide a rationale
for each – or – note if you think this was an unnecessary diagnostic test based on all
you know about Sue.
DIAGNOSTIC TEST
Pap smear
RESULTS
WNL pap.
Pregnancy test
Negative.
Beck Self-Report
Depression Scale
WNL.
Electrolytes, LFT, renal
function, cholesterol
Not done, only if >30-40 for
baseline.
H/H
Not done, no complaints of
RATIONALE
Sue is a 26 year old female
that is sexually active who
wants to start a new
method of birth control. This
is her well exam.
Sue has used condoms
occasionally as her only
method of contraception for
the past two years.
Condoms are only used
“when they are felt
necessary”.
Sue appears depressed
during her physical
examination and with her
review of symptoms. She
seems overwhelmed with
her responsibilities. She is
tearful and unhappy with
her relationship with her
husband.
Although these tests are
generally indicated for ages
>30-40, they could be
beneficial in determining
Sue’s baseline due to her
complaints of feeling tired
all the time, decreased
appetite, and appearing thin
and pale.
I would probably do an H/H
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heavy bleeding.
TSH
No problems with
amenorrhea or excessive
fatigue.
Other diagnostic tests?
None
due to the possibility of Sue
being anemic due her
complaints of feeling tired,
appearing pale and thin,
and poor dietary habits.
Although, her tiredness
could be contributed to her
working full-time and taking
care of 3 children,
responsibilities at home,
and activity level, I would
still perform an H/H.
Sue does not present with
classic symptoms of
hypothyroidism. She does
complains of being tired all
the time and reports a
decrease in sexual interest,
but this can be contributed
to her busy schedule. The
American Thyroid
Association does not
recommend baseline
screening until 35 years of
age.
None
DIAGNOSES
After review of your differential diagnoses, what final diagnoses are appropriate for
Sue? (List all that apply).
1. Altered family planning
2. Altered health maintenance
3. Poor dietary habits
4. Altered family processes
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THERAPEUTIC PLAN
1. What are the issues to consider when deciding on a contraceptive method for Sue?
For Sue, it is important to consider that she does not want any more children and has
become pregnant using oral contraceptives in the past. Also, Sue takes Tegretol for
seizures and smokes tobacco. Financial burdens need to be considered as Sue and her
husband work full-time and has medical insurance coverage, but her financial situation
seems to be strained. Other issues to consider include: the safety of the method
chosen, frequency of sexual relations, risk of sexually transmitted diseases, cost, and
ability to comply with the method, and health and medical conditions of the patient.
2. Below are a variety of possible contraceptives to choose from? Please complete the
chart for each product.
Type
Cervical cap
Insurance
Coverage
Yes
Failure
Rate
Condom
(Male &
Female)
Available
only with a
prescription
Diaphragm
Yes
DMPA
(DepoProvera)
Yes
IUD
Yes
PU- 1%
TU- 1%
Implanon
Yes
PU- 1%
TU- 1%
Norplant
Yes
PU- 1%
TU- 1%
PU- 9-26%
TU- 1632%
Male:
PU- 2%
TU- 15%
Female:
PU- 5%
TU- 21%
PU- 6%
TU 16%
PU- 1%
TU- 3%
Tegretol
Interaction
None
Office
Use
No
Private
No
Approx.
Cost/Yr
$35-$60
None
No
No
$150
None
No
No
$60
Tegretol can
decrease plasma
concentrations and
pharmacologic effects
of
medroxygrogesterone
Tegretol will decrease
the level or effect of
hormone releasing
IUDs by affecting
hepatic/intestinal
enzyme CYP3A4
metabolism.
IUDs that do not
contain hormones do
not result in an
interaction
Tegretol will decrease
the level or effect of
Implanon by affecting
hepatic/intestinal
enzyme CYP3A4
metabolism.
Tegretol will decrease
the level or effect of
Norplant by affecting
hepatic/intestinal
enzyme CYP3A4
Yes
Yes
$220$460
Yes
Yes
$100
Yes
Yes
$150$180
Yes
Yes
$95$115
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Birth Control
Pills
Yes
PU- 1%
TU- 8%
Nuva Ring
Yes
TU- 1%
PU- 8%
Essure
Yes
Procedure
Contraceptive Yes
Patch (Ortho
Evra)
PU- 1%
TU- 1%
Other? Tubal
Ligation
Yes
1%
Vaginal
Sponge
Spermicide
Only with a
prescription
Only with a
prescription
PU- 9-20%
TU- 1632%
PU- 18%
TU- 29%
PU- 1%
TU- 1%
metabolism.
Estrogen containing
pills and some
progestin will
increase the level of
Tegretol by affecting
hepatic/intestinal
enzyme CYP3A4
metabolism. The
efficacy of hormonal
contraceptives may
be reduced.
Nuva Ring will
increase the level of
Tegretol by affecting
the hepatic/intestinal
enzyme CYP3A4
metabolism. The
efficacy of hormonal
contraceptives may
be reduced.
None
No
Yes
$160$600
No
yes
$160$600
Yes
Yes
$200
Ethinylestradiol will
increase the level of
Tegretol by affecting
hepatic/intestinal
enzyme CYP3A4
metabolism. The
efficacy of hormonal
contraceptives may
be reduced.
None
No
Yes
$160$600
No
Yes
$200
None
No
No
$500
None
No
No
$180
3. What are factors that should be considered when Sue decides on a contraceptive?
Factors that should be considered when Sue decides on a contraceptive include: ease
of use, interactions with her current medications, cost, efficacy, side effects, and
likelihood Sue will use contraceptive properly and as directed.
4. Identify the birth control method you decide is best for Sue; provide rationale (pros
and cons) for this selection; and list the specific side effects you need to discuss with
Sue regarding this product?
I would choose an IUD that does not release hormones for Sue to use as a birth control
method. The importance of choosing an IUD that does not release hormones is
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essential due to Sue taking Tegretol as the IUDs that release hormones can alter the
effects of the Tegretol levels. I would choose the IUD, ParaGard, Copper T-380A.
Pros to Copper T-380A (ParaGard)
 99% effective
 Inexpensive and covered by insurance
 Can be reversed or removed
 No hormones are released, therefore, safe to use with Tegretol
 Inserted in office
 Does not alter of affect hormone levels
 Convenient- once inserted, nothing else required
 Can provide continuous pregnancy prevention for 10 years and can be removed
anytime within the 10 years without difficulty
Cons to Copper T-380A (ParaGard)
 May experience spotting between first few menstrual cycles when first inserted,
but usually subsides within 2-3 months of insertion
 May increase menstrual flow 50-75%, thus increasing risk for anemia
 May cause lower back and/or lower abdominal pain
 May cause vaginal discharge due to increased inflammation of the vagina,
therefore increasing the risk of PID within the first month of insertion
 May cause pain during sexual intercourse
 May cause vaginal discharge
Side effects of ParaGard that need to be discussed:
1. If pregnancy occurs with use of ParaGard, ParaGard should be removed because of
the risk of spontaneous abortion and premature delivery. Removal of the ParaGard may
be followed by pregnancy loss.
2. Within the first 20 days of insertion, you will be at an increased risk of developing PID
due to an increase in vaginal inflammation.
3. Expulsion of the IUD can occur, usually during the first few months after insertion and
during the menses. Sue should check for the strings of the IUD after each menstrual
cycle.
4. ParaGard may cause anemia, weight gain, headache, and decreased libido.
5. Lower abdominal pain and/or lower back pain may occur during the first few months
of insertion due to increase in menstrual flow. An increase in menstrual flow may cause
anemia. These side effects usually resolve within 6 months of insertion.
5. When should Sue return for follow up?
Sue should return for a follow up after her next menses in order to address any
concerns regarding the contraceptive, adverse effects, ensures the absence of
infection, and check for the presence of the strings.
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6. What recommendations can you make to Sue regarding her other diagnoses (list
each diagnosis, recommendation, and appropriate education separately)?
1. Family Planning
 Sue should be encouraged to identify factors that affect communication
barriers between herself and her husband. If factors can be identified and
removed, communication can be improved.
 Schedule follow-up for Sue after next menses for assessment and to
address any concerns regarding her IUD.
2. Altered Health Maintenance
 Sue should be assessed regarding for the extent of knowledge she has
regarding the importance of health maintenance behaviors. Sue should be
provided with education regarding how to make good lifestyle choices for
herself and her family.
 Importance of eating a balanced diet on a regular basis- education should
be provided to Sue on healthy food choices. Sue should be encouraged to
maintain a healthy diet on a daily basis.
 Importance of increasing exercise- Sue should be encouraged to exercise
at least 30 minutes three times a week. Regular exercise will increase Sue’s
energy and help decrease fatigue.
 Importance of smoking cessation- Sue should be provided with smoking
cessation education and various options on how to quit smoking.
 Sue should be educated on the importance of obtaining and seeing a
primary care physician and dentist on a regular basis in order to identify
and treat health problems early.
 Sue should be encouraged to report any symptoms she may have to a
healthcare professional in a timely manner in order to provide early
interventions for any health condition she may have.
3. Poor Dietary Habits
 Sue should be encouraged to maintain a balanced diet on a daily basis.
 Healthy food choices (meals and snacks) should be provided for Sue.
 Encourage a diet intake consisting of fruits, vegetables, nuts/legumes, lowfat dairy, and lowered intake of beverages containing sugar, beef, and
limited sodium intake.
4. Altered Family Processes
 Increase positive interactions and encourage increased communication
between Sue and her husband regarding issues that affect their family.
 Encourage Sue and her husband to seek a marriage counselor in order to
assist in identifying areas of improvement in their methods of
communication and stress reduction
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