Family Planning Case Write-Up
Utilizing a patient you have seen in the clinic, complete a write-up on a case involving family planning and contraceptive counseling. You will also be graded on the ability to select an appropriate patient encounter or visit in completing this assignment.
Please make sure to consult the attached rubric prior to starting.
omprehensive Case Write-Up
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List View
Exceeds Standards Meets Standards Below Standards
Chief Complaint
Points:
10 (10.00%)
Includes CC/Reason for Visit and the Pertinent HPI
Points:
8 (8.00%)
Misses one of the requirements
Points:
6 (6.00%)
Not included
Pertinent History
Points:
10 (10.00%)
Medical, surgical, family, and social
Points:
8 (8.00%)
Misses one of the requirements
Points:
6 (6.00%)
Misses 2 or more of the requirements
Review of System
Points:
20 (20.00%)
Complete with each physical system addressed with clear narrative (do not write WNLs-within normal limits†or other variation. Please include next to state what is considered ‘normal’)
Points:
16 (16.00%)
Incomplete review of system missing 3 or less components
Points:
14 (14.00%)
No ROS or missing 4 or more components
Physical Exam
Points:
20 (20.00%)
VS and each system addressed completely. Include pertinent positive and pertinent negative findings. Include lab tests ordered
Points:
16 (16.00%)
Incomplete examination missing 3 or fewer components and/or missing up to 3 pertinent positives/negatives and/or missing needed lab exams
Points:
14 (14.00%)
Missing 4 or more of the components
Diagnosis
Points:
10 (10.00%)
Diagnosis: Include citation
Points:
8 (8.00%)
Diagnosis: No citation
Points:
6 (6.00%)
No diagnosis
Interventions
Points:
20 (20.00%)
Include labs/tests ordered that are pending, patient teaching, pharmacological and non-pharmacological interventions, referrals, and other preventative measures. Citations for sources of interventions Coding and Billing
Points:
16 (16.00%)
Missing 3 or more components and/or does not include dosing and instructions for medications
Points:
14 (14.00%)
Missing 4 or more of the required components
Formating
Points:
10 (10.00%)
No errors in grammar and spelling APA formate correctly for citations and references
Points:
8 (8.00%)
up to 3 spelling or grammar errors OR 3 APA errors
Points:
6 (6.00%)
4 or more errors in spelling and/ or grammar AND/OR 4 or more APA errors
Name:Comprehensive Case Write-Up
Family Planning Case Write Up
Name
Institution
Date
Family Planning Case Write Up
Chief Complaint
The patient is a 32-year-old African-American female who presents to the clinic complaining of swelling and pain in the left leg.
Pertinent History
The patient has a history of knee surgery after an accident nine months ago. She is also on the combined pill as a method of contraception.
Review of Systems:
GENERAL: Weight gain. Denies weakness or body fatigue.
HEENT: No blurred vision, hearing loss, nasal congestion, sneezing, runny nose, or sore throat.
SKIN: Warm to touch especially on the affected leg. No rash
CARDIOVASCULAR: No chest pressure, chest pain, or chest discomfort. Has no palpations.
RESPIRATORY: No shortness of breath
GASTROINTESTINAL: No anorexia, no nausea, or vomiting. No abdominal pain
GENITOURINARY: No burning on urination or any significant changes in bladder or bowel
control
NEUROLOGICAL: No dizziness, no paralysis, or syncope
MUSCULOSKELETAL: Pain on the left leg. No back pain or stiffness
HEMATOLOGIC: No anemia or bleeding
LYMPHATICS: No enlarged nodes. Has no history of splenectomy
PSYCHIATRIC: No history of anxiety or depression
ENDOCRINOLOGIC: No reports of cold or heat intolerance or sweating. No polyuria or even
polydipsia
REPRODUCTIVE: Sexually active. No reports of vaginal bleeding or discharge
ALLERGIES: No history of allergies
Physical Examination
Vitals: BP 120/74, P64, Weight 140, Height 5’6
Musculoskeletal: pain and swelling
Diagnosis
The primary diagnosis for the patient is deep vein thrombosis based on her clinical manifestation and medical history. Deep vein thrombosis (DVT) is a sub-set of venous thromboembolism (VTE). Deep vein thrombosis accounts for two-thirds of venous thromboembolism cases. The signs and symptoms of deep vein thrombosis include swelling on the affected leg, pain on the leg, a red or skin discoloration on the leg as well as a feeling of warmth on the leg. Risk factors for patients developing deep vein thrombosis include major surgery, a prolonged period of immobility, trauma, and the use of hormonal contraceptives (McDaid et al., 2017). Patients diagnosed with deep vein thrombosis can suffer from complications such as pulmonary embolism which can be asymptomatic or symptomatic dyspnea, hypoxemia, or tachycardia.
Interventions
Comprehensive assessment and diagnostic criteria would be essential to accurately diagnose the condition. Therefore, a clinical examination alone would not be sufficient to diagnose DVT. It would be vital to look at patient history and triggers such as surgery, trauma, immobilization, or hormonal treatment. A clinician would need to also use the Wells score to determine the probability of DVT (Stone et al., 2017). A score of ≤ 2 points indicates a low probability of having DVT. An ultrasound scan on the leg vein system including the distal veins has been indicated to be accurate for a patient with DVT.
The goal for DVT treatment is preventing the clot from becoming bigger, reducing the chance of developing another DVT, and at the same time preventing the clot from breaking loose and traveling to the lungs (Stone et al., 2017). The pharmacological agents that are commonly used for the management of DVT are blood thinners which are also known as anticoagulants. They work by preventing clots from becoming bigger and reducing the risks of developing more clots. They can either be administered orally or intravenously. Injectable blood thinners include enoxaparin and fondaparinux. Patients with severe DVT are prescribed thrombolytics. Similarly, patients can be recommended to use compression stockings which prevent blood pooling and subsequent clotting.
Besides the administration of medication, it would be important to educate the patient about the risk of hormonal contraceptives in the development of DVT. I would therefore recommend the patient to use alternative contraceptive methods like the use of condoms or non-hormonal intrauterine devices.
References
McDaid, A., Logette, E., Buchillier, V., Muriset, M., Suchon, P., Pache, T. D., … & Michaud, J. (2017). Risk prediction of developing venous thrombosis in combined oral contraceptive users. PLoS One, 12(7), e0182041. https://doi.org/10.1371/journal.pone.0182041
Stone, J., Hangge, P., Albadawi, H., Wallace, A., Shamoun, F., Knuttien, M. G., Naidu, S., & Oklu, R. (2017). Deep vein thrombosis: pathogenesis, diagnosis, and medical management. Cardiovascular diagnosis and therapy, 7(Suppl 3), S276–S284. https://doi.org/10.21037/cdt.2017.09.01