Case Study 2
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”Weight148(BMI 23.1),BP 118/72 P68
• HEENT: wnl
• Neck: supple without adenopathy
• Lungs/CV: wnl
• Breast: soft, fibrocystic changes bilaterally,without masses, dimpling or discharge
• Abd: soft, +BS, no tenderness
• VVBSU: wnl, except1st
degree cystocele
• Cervix: firm, smooth, parous, without CMT
• Uterus: RV, mobile,non-tender,approximately 10 cm,
• Adnexa: without masses or tenderness
Episodic focused Note- Contraceptive options
Patient Information: E.G., 38y.o. female, race unknown
S.
CC: discuss contraceptive options
HPI: E. G. is a 38 y.o. female who presents to office to discuss contraceptive options. She is
G5P5LC6. She does not really want another child, but her new partner has not fathered a child.
Current medications: Vitamin C (dosage and frequency unknown)
Allergies: No known drug, food, and environmental allergies
PMHx: exercise- induced asthma, migraines, irritable bowel syndrome
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