Margaret Is A 40-Year-Old White Female For Her Annual Exam ✓ Solved

Margaret Is A 40 Year Old White Female In For Her Annual Exam

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 that 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 her 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 the 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 retroverted, 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.

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In evaluating Margaret's case, it is important to address several key aspects of her health concerns, including suitable contraceptive options, potential contraindications, education regarding her health conditions, and how a normal pelvic examination impacts contraceptive decision-making.

1. Appropriate Contraceptive Options

Given Margaret's age, smoking habits, and health history, various contraceptive options should be considered. Non-hormonal methods such as the copper intrauterine device (IUD), condoms, or spermicide are recommended. The copper IUD provides long-term contraception and does not involve hormonal risks associated with smoking (American College of Obstetricians and Gynecologists, 2020).

Additionally, the use of contraceptive implants and hormonal birth control methods, such as the progestin-only pill or hormonal IUDs, could also be appropriate if Margaret's smoking do not contraindicate their usage. Progestin-only methods are generally safer for women who smoke as they do not carry the same risks as combination hormonal methods (Monaghan et al., 2019).

2. Contraindicated Contraceptive Options

For a patient like Margaret, the use of combined oral contraceptives (COCs) such as the traditional "pill" may be contraindicated. This is particularly relevant due to her smoking history, especially given that she smokes a pack per day. The use of COCs increases the risk of thromboembolic events, which are exacerbated by smoking (US Preventive Services Task Force, 2018).

Other hormonal methods combining estrogen and progesterone, such as the patch and vaginal ring, would also be contraindicated due to her smoking (Curtis et al., 2019). It is essential to provide her with all the necessary information regarding these risks to ensure informed decision-making.

3. Patient Education

Patient education is a critical component of Margaret's care. Key points of education include the relationship between smoking and hormonal contraception, highlighting the increased risk of blood clots and other health issues. She should be informed about the potential long-term effects of smoking, particularly in a stressful state, and encouraged to seek support for smoking cessation (Centers for Disease Control and Prevention, 2021).

Margaret should also be educated about her options surrounding contraceptive methods. Information on the effectiveness, advantages, and disadvantages of each method must be thoroughly explained to allow her to make an informed decision (Ferguson et al., 2020). Techniques for managing stress and maintaining a balanced diet should also be discussed as part of her overall health improvement plan, given her recent weight gain and feelings of stress.

4. Impact of a Normal Pelvic Exam

Margaret's normal pelvic examination results are reassuring and influence her contraceptive options. A normal Pap smear indicates no current cervical dysplasia, thus not complicating the choice of contraception. However, this does not alter the contraindications related to smoking and the use of hormonal contraceptives (Weir et al., 2022). The normal exam provides confidence in her reproductive health, giving her a wider range of options only limited by her smoking.

In conclusion, Margaret's case illustrates the need for a comprehensive approach to contraceptive counseling, particularly in the context of her personal circumstances and lifestyle choices. Addressing each aspect, from appropriate contraceptive methods to patient education and the influence of her health screening results, forms the basis for a thoughtful and respectful decision-making process in her healthcare. This approach not only enhances her understanding but also empowers her to make informed choices about her reproductive health.

References

• American College of Obstetricians and Gynecologists. (2020). Management of contraception in women who smoke.
• Centers for Disease Control and Prevention. (2021). Smoking and women's health.
• Curtis, K. M., et al. (2019). U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recommendations and Reports, 65(3), 1-104.
• Ferguson, K. D., et al. (2020). Contraceptive counseling: A systematic review of the literature. Women’s Health, 16(2), 1-12.
• Monaghan, K., et al. (2019). Progestin-only contraceptive methods for women who smoke. Journal of Clinical Endocrinology & Metabolism, 104(6), 2684-2690.
• US Preventive Services Task Force. (2018). Contraception counseling for women at increased risk for cardiovascular disease.
• Weir, H. K., et al. (2022). The implications of cervical cancer screening for contraceptive use in women. Obstetrics & Gynecology, 139(3), 451-457.