Diagnostics: None needed. Complete blood work as a routine follow up.

  1. Women’s wellness exam:

Continue with annual visits. Continue with self-breast exams.

  1. Oral Contraception maintenance:

Continue taking pills daily at approximately the same time with food. Prescription is renewed for one year. Return for annual maintenance visit.

  1. Sexually active:

Patient is encouraged to continue the use of condoms on every sexual encounter. The importance of condom usage is summed up by the CDC, “ Consistent and correct use of male latex condoms can reduce (though not eliminate) the risk of STD transmission. To achieve the maximum protective effect, condoms must be used both consistently and correctly. Inconsistent use can lead to STD acquisition because transmission can occur with a single act of intercourse with an infected partner. “(CDC, Condoms and STDs: Fact Sheet for Public Health Personnel).

Patient is offered protection against HPV and the risk for cervical cancer by receiving a vaccine. The HPV vaccine is indicated for girls in the onset of sexual activity. The CDC provided this information regarding the vaccine that was presented to the patient, ” (Gardasil) vaccine containing HPV types 6, 11, 16, and 18. Both vaccines offer protection against the HPV types that cause 70% of cervical cancers (i.e., types 16 and 18), and the quadrivalent HPV vaccine also protects against the types that cause 90% of genital warts (i.e., types 6 and 11)”. (CDC 2010, Sexually Transmitted Disease Guidelines) The patient was given the CDC website information and pamphlets from the office supplied and supported from the CDC and Gardasil manufacturers.

Other STI’s were listed for the patient so she is aware of the possibilities.  This website lists all possible sexually transmitted diseases and the facts and figures surrounding them. http://www.emedicinehealth.com/sexually_transmitted_diseases/article_em.htm. The website was given to the patient so further information could be researched.

She declined the Gardasil vaccine at this time and states she will continue with condom use when she engages in sexual activity; in her next relationship. Patient is also instructed to contact the office if she experiences any vaginal or abdominal pain, discharge, change in menses, or any other abnormalities for her.

  1. Weight gain:

The patient was shown the BMI chart and explained that she is still in the normal range provided by the U.S. Department of Health and Human Services. Reasons for her weight gain could be her oral contraception, hormone changes, thyroid issues, dietary intake and exercise habit changes. The patient was instructed to keep a diet and exercise log and weigh herself once a week, the same time and wearing the same clothes. Keep a food diary is suggested by the U.S. Department of Health and Human Services. “Knowing what you eat now will help you make changes if necessary. Starting today, write down: When you eat, what you eat, how much you eat, where and with whom you eat, how you are feeling when you eat.” (2010, Eat Healthy, Healthfinder.gov) Dietary Guidelines of America suggested in its action plan, “Identify approaches for assessing and tracking for use by health professionals to identify overweight and obesity and implement appropriate interventions. ” (2010). Eating disorders were explained and warned against. (ie. Anorexia, Bulimia, Overeating) Patient does not seem to present with any symptoms or signs of an eating disorder. The National Institute for mental health explains that, “An eating disorderis marked by extremes. It is presentwhen a person experiencessevere disturbances in eatingbehavior, such as extreme reductionof food intake or extremeovereating, or feelings of extremedistress or concern about bodyweight or shape. ” (2007, What are Eating Disorders?)  Patient and care givers will be able to reference journal if extreme weight loss or gain continues.

Follow up with the patient to report results of intervention(s).

The patient was educated on various measures to take in regards to weight gain despite having maintained BMI.  They include dietary changes and exercising regularly. Therefore, it is important for the medical practitioner to evaluate an understanding of this by asking questions and putting emphasis on certain areas such as checking weight on a weekly basis to determine any changes made.  Failure to lose weight, the patient should revisit the clinic for further investigations such as Thyroid Function Test. Research has shown that an underactive thyroid gland/ hypothyroidism results in decreased metabolic rate (Schneider, 2011). Therefore, such patients are prone to weight gain.

Moreover, follow up on appropriate use of condom and an understanding of various sexually transmitted infections is necessary for such a scenario. Therefore, the health practitioner should demonstrate the use of a condom and allow the patient to give a return demonstration. The patient should also mention some of the STIs known to her and the preventative measures to be taken. Follow-up should be done regularly and patient tested for STIs.

As part of follow-up, routine checkup and screening of breast cancer and cervical cancer should be ensured. The clinician should perform breast examination on every visit and educate the patient on how to perform it on self. Cervical cancer should as well be done at least on an annual basis. The checks will help detect any abnormalities, which should be addressed immediately.

What do you wish you had done initially that you didn’t think of?

According to the case scenario, it is vivid that the patient could be undergoing through some psychological problems such as stress related to a broken relationship and weight gain.  Therefore, it is significant to refer this patient to a psychologist to aid in stress management. Some of the techniques that could be adopted include indulging in positive relaxation events such as yoga and meditation (Seaward, 2014). Others include walking, adventure and sporting activities. This will help the patient to stay positive and live a healthy lifestyle.

 

 

References:

Bickley,L. (2009) Bates guide to physical examination and history taking 10th edition. Lippincott

Williams and Wilkins. Philadelphia, PA.

Calculate your BMI. Retrieved on June 27, 2011 from National Heart, Blood

and Lung Institute, Department of U.S. Health and Human Services at

http://www.nhlbisupport.com/bmi/

Condoms and STD’s: A Fact Sheet for Health Care Personal. April 6, 2011. Retrieved on June

26, 2011 from Center for Disease Control,

http://www.cdc.gov/condomeffectiveness/latex.htm.

Domino, F. J. (2010). The 5-minute clinical consult 2011 19th edition. Lippincott

Williams and Wilkins, Philadelphia, PA

Sexually Transmitted Diseases. (2011). Retrieved on June 27, 2011 from

http://www.emedicinehealth.com/sexually_transmitted_diseases/article_em.htm

STD’s Treatment Guidlines-2010, Human Papilloma Virus (HPV) Infection. January 28, 2011.

Retrieved on June 26, 2011 from Center for Disease Control,

http://www.cdc.gov/std/treatment/2010/hpv.htm.

Take Action! Eat Healthy. U.S. Department of Health and Human Services. 2010. Retrieved on

June 27, 2011 from

http://www.healthfinder.gov/prevention/ViewTopic.aspx?topicID=21&cnt=1&areaID=5

U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary

            Guidelines for Americans, 2010. 7th Edition, pg 58. Washington, DC: U.S. Government

PrintingOffice, December 2010.

What are eating disorders? (2007). U.S. Department of Health and Human Services and The

National Institutes of Mental Health. NIH Publication. Retrieved on June 26, 2010 from

http://www.nimh.nih.gov/health/publications/eating-disorders/nimheatingdisorders.pdf

 

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