CASE PRESENTATION:

FAMILY PLANNING
DANIELLE A. ALVERSON BSN, RN
SPRING ARBOR UNIVERSITY
OB/GYN CLINICAL ROTATION
PATIENT INFORMATION

• Name: Not identified for patient privacy.

• Age: 30 years old
• Sex: Female
• Chief Complaint: Patient is being seen today for annual exam and family
planning conversation. Patient states” I am 30 and I am not getting any younger
so my husband and I are ready to start a family soon. I know I have health
concerns and certain medications I may need to stop before getting pregnant”.
HPI

• Patient presents today for annual exam with PAP and to have a family
planning conversation. Patient has multiple co-morbidities and is on quite a
lot of medications that may needs to be stopped prior to conceiving. Patient
sees a rheumatologist and pulmonologist for her conditions. They told her to
consult with an OB/GYN regarding her medications.
MEDICATIONS
• Zofran 4mg as needed
• Prilosec 20mg daily
• Naproxen 500mg TID
• Singulair 10mg daily
• Mobic 15mg daily
• Seasonique daily
• Duo neb q 6 hours as needed
• Atrovent daily
• Allegra dialy
• Flexeril as needed
• Celebrex daily
PMI

• Childhood Illnesses: Mild Spina Bifida, Asthma.

• Adult: Continues to have problems with her asthma and lungs, possible she has
rheumatoid arthritis.
• Surgeries: colposcopy, bunionectomy.
• All vaccinations are UTD.
• Last Pap Smear: Patient is unsure of date one will be collected at this
appointment.
FAMILY HISTORY

• Patient denies any family history of cancer. Also denies any significant
family history including HTN, diabetes and heart disease.
SOCIAL HISTORY

• Patient lives at home with her husband. Patient states they got married last
year. Patient works outside of the home. Patient denies ever smoking or using
illicit drugs. Patient states she rarely consumes alcohol.
 REVIEW OF SYSTEMS
• General: Patient states overall she is feeling well. Does state that her asthma flares up and givers her trouble. Patient also
states her rheumatologist is trying to figure out why she gets so much inflammation in her joints. States at times she has pain
related to that.
• Cardiovascular: Patient denies any chest pain or pressure. Does state at times she gets short of breath due to her asthma.
Patient denies any swelling in her legs.
• Skin: Patient denies any changes in her skin, no changes in moles, no open areas or lesions.
• Eyes: Patient denies any trouble seeing, states she does wear glasses but can see fine with her glasses. Patient denies any
blurred vision or drainage from her eyes.
• Gastrointestinal: Patient denies any constipation or diarrhea. Patient does state she has been having some abdominal pain
lately.
• Nose/Mouth/Throat: Patient denies any trouble chewing or swallowing. No sores in her mouth or any drainage from her nose.
• Neurological: Patient states she does occasionally get headaches. Denies any numbness or tingling in her extremities.
REVIEW OF SYSTEMS CONTINUED

• Genitourinary/Gynecological: Patient denies any difficulty urinating,

frequency or burning. Also denies any abnormal vaginal discharge or itching.
Patient state her periods are usually regular and light lasting 5 days. Patient
does have some abdominal cramping and tenderness at times.
• Breast: Patient states she does self breast exams at home. Denies any changes
in her breast.
 VITALS: BP:122/70 P:65 R:16 WT: 155LBS HT:5’2”

PHYSICAL EXAM
• General Appearance: Patient appears to be doing well. Patient is noted to be mildly obese for her
stature. Patient does not appear to be in any distress. Patient answers all questions appropriately and
is cooperative. Her speech is clear and easy to understand.
• Skin: Patients hair is evenly distributed on her scalp. Color is appropriate for ethnicity. No bruises,
lesions or rashes noted.
• HEENT: Head is normal cephalic. Eyes are symmetrical, PERRL, conjunctiva is pink, sclera is
white, no drainage noted. Eye lashes on top curl up, eye lashes on bottom curl down. Bilateral ears
are clean, no cerumen noted. Tympanic membrane is visible. Cone of light is in appropriate location.
No fluid noted. No tenderness to frontal or maxillary sinuses. Nose is midline, no septum deviation.
Lips are symmetrical, pink and moist. ROM in neck is normal.
PHYSICAL EXAM CONTINUED

• Respiratory: Chest expansion is symmetrical, LSCTA, no cough noted.

• Cardiovascular: Heart rate and rhythm is normal, no murmurs noted.
• Gastrointestinal: Abdomen is soft, mild pain with palpation, bowel sounds active x 4.
• Genitourinary: Pelvic exam complete. No lesions or cyst noted on cervix. Patient does not
have tenderness when the cervix is palpated. Vaginal tissue appears to be normal. No blood or
abnormal discharge noted. PAP collected.
• Musculoskeletal: No numbness or tingling noted in extremities. ROM WNL in all extremities.
• Neurological: 2-12 cranial nerves intact. Alert and oriented x 4. Strength in arms and legs is
5/5. Hand grasp are equal. Gait is stead when walking.
ASSESSMENT AND PLAN

• Lab test: PAP and HPV samples were collected and will be sent out for
testing.
• Differential diagnosis: There is no differential diagnosis patient was just
being seen for annual exam and family planning conversation.
• Diagnosis: Annual exam
• Plan: Will see patient back in one year for annual exam or sooner if patient
becomes pregnant or has concerns.
EDUCATION AND TEACHING
• Spoke with physician on staff Dr. Gates regarding patients medications and what she
would recommend the patient stopping or switching to a pregnancy approved medication.
Dr. Gates recommended patient stopping her flexeril Celebrex and naproxen.
• Educated patient on the important of eating a healthy diet, drinking plenty of water and
get 30 minutes a day of some kind of exercise to prepare her body for pregnancy. Also
instructed patient on medications she needed to stop taking before becoming pregnant.
Talked with patient about when she should stop her birth control when deciding to
become pregnant. Stressed the importance of patient taking a prenatal vitamin with at
least 0.4mg of folic acid especially with her history of spina bifida. Patient information
booklet given to patient with information on calcium intake, vitamin intake, exercise and
family planning.
EVIDENCE
• Neural tube defects affect the brain and spine and occur early in pregnancy. They are
caused from improper closure of the embryonic neural tube. This can cause a variety of
disabilities in the child and even death. The most common defects are anencephaly
which is when the brain in under developed and the skull does not completely form and
spina bifida which is when the spinal cord does not close completely. On average each
year there are 6.5 cases per 10,000 live births. Women who personal have a history of
spina bifida or a family history of spina bifida have a increased risk of having a
pregnancy affected by neural tube defects. Folic acid during the preconception period
can prevent neural tube defects. Folic acid is a synthetic form of folate. It is water
soluble B9. Most women do not receive the recommended amount through nutrition. It
is recommended that women for are planning pregnancy or are capable of becoming
pregnant take folic acid 0.4-0.8mg daily. (USPSTF, 2017, p.652 A-C)
REFERENCE

• U.S. Preventative Services Task Force. (2017). Folic Acid Supplementation

for the Prevention of Neural Tube Defects: Recommendation Statement.
American Family Physician. Vol. 95 No.10. Retrieved from:
https://www.aafp.org/afp/2017/0515/od4.pdf
• Dr. Candance Gates. (2018). Henry Ford Allegiance Health Women’s Health
Center.