NRNP Case Study 2 Week 3 (1 Solved Case)
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Case Study 2
Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your clinic today to discuss
contraceptive options. She states that she is not interested in having more children but her new
partner has never fathered a child. Her medical history is remarkable for exercise-induced
asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her
social history is negative for alcohol, tobacco, and recreational drugs. She has no known drug
allergies and takes only vitamin C. Hospitalizations were only for childbirth. 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.
Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68
HEENT: wnl
Neck: supple without adenopathy
Lungs/CV: wnl
Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge
Abd: soft, +BS, no tenderness
VVBSU: wnl, except 1st degree cystocele
Cervix: firm, smooth, parous, without CMT
Uterus: RV, mobile, non-tender, approximately 10 cm,
Adnexa: without masses or tenderness
Episodic focused Note- Contraceptive options
Patient Information: E.G., 38y.o. female, race unknown
S.
CC: discuss contraceptive options
HPI: E. G. is a 38 y.o. female who presents to office to discuss contraceptive options. She is
G5P5LC6. She does not really want another child, but her new partner has not fathered a child.
Current medications: Vitamin C (dosage and frequency unknown)
Allergies: No known drug, food, and environmental allergies
PMHx: exercise- induced asthma, migraines, irritable bowel syndrome
Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your clinic today to discuss
contraceptive options. She states that she is not interested in having more children but her new
partner has never fathered a child. Her medical history is remarkable for exercise-induced
asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her
social history is negative for alcohol, tobacco, and recreational drugs. She has no known drug
allergies and takes only vitamin C. Hospitalizations were only for childbirth. 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.
Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68
HEENT: wnl
Neck: supple without adenopathy
Lungs/CV: wnl
Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge
Abd: soft, +BS, no tenderness
VVBSU: wnl, except 1st degree cystocele
Cervix: firm, smooth, parous, without CMT
Uterus: RV, mobile, non-tender, approximately 10 cm,
Adnexa: without masses or tenderness
Episodic focused Note- Contraceptive options
Patient Information: E.G., 38y.o. female, race unknown
S.
CC: discuss contraceptive options
HPI: E. G. is a 38 y.o. female who presents to office to discuss contraceptive options. She is
G5P5LC6. She does not really want another child, but her new partner has not fathered a child.
Current medications: Vitamin C (dosage and frequency unknown)
Allergies: No known drug, food, and environmental allergies
PMHx: exercise- induced asthma, migraines, irritable bowel syndrome
Vaccination history (unknown)
Hospitalizations for childbirth (unknown if any complications occurred, length of stay)
Social and Substance Hx: Patient denies smoking, drinking alcohol, and use of recreational
drugs.
Family Hx:
Dad: alive- Basal cell skin cancer
Mom: alive- osteopenia, fibromyalgia
Paternal grandparents: deceased- cause: car accident
Maternal grandmother: alive- dementia
Maternal grandfather: alive- COPD
Sister (older): alive- no medical problems
Brother (younger): alive- no medical problems
Past surgical history: tonsillectomy (childhood)
Mental Hx: no data available
Violence Hx: no data available
Reproductive Hx: G5P5LC6, no info on LMP, length of menstrual cycle, dates of previous
pregnancies, history of complications with childbirth
ROS: (not obtained) only information collected is
Hospitalizations for childbirth (unknown if any complications occurred, length of stay)
Social and Substance Hx: Patient denies smoking, drinking alcohol, and use of recreational
drugs.
Family Hx:
Dad: alive- Basal cell skin cancer
Mom: alive- osteopenia, fibromyalgia
Paternal grandparents: deceased- cause: car accident
Maternal grandmother: alive- dementia
Maternal grandfather: alive- COPD
Sister (older): alive- no medical problems
Brother (younger): alive- no medical problems
Past surgical history: tonsillectomy (childhood)
Mental Hx: no data available
Violence Hx: no data available
Reproductive Hx: G5P5LC6, no info on LMP, length of menstrual cycle, dates of previous
pregnancies, history of complications with childbirth
ROS: (not obtained) only information collected is
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