Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests you might recommend and explain why.
Response 1
Patient Information:
E.G., 38, Female
S.
CC “discuss contraceptive options.”
HPI: 38-year-old female presents to the office to discuss contraceptive management options. She is a G5P5006. She denies wanting anymore children, but her partner has never fathered a child. She has a history of migraines. She is currently not using any form of contraceptive.
Current Medications: Vitamin C
Allergies: NKDA
PMHx: Positive for exercise-induced asthma, migraines, and IBS. Surgeries: Tonsillectomy. Hospitalizations: childbirth.
Soc Hx: Denies use of alcohol, tobacco, and recreational drugs. She is in a relationship with new partner who does not have children.
Fam Hx: 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.
ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Shortness of breath with exercise. Denies cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, or vomiting. Positive for occasional abdominal pain and diarrhea due to IBS. Denies abdominal pain and diarrhea today.
GENITOURINARY: Denies burning on urination. Last menstrual period: unknown.
NEUROLOGICAL: Positive for migraines. Denies dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: History of exercise-induced asthma. Denies history of hives, eczema or rhinitis.
O.
Physical exam:
VS: Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68
GENERAL APPEARANCE: alert, in no acute distress.
HEENT: Head: Normocephalic, atraumat
