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Elaine Case Study
Patient Information:
Elaine Goodwin is a 38-year-old Caucasian female. Elaine works full-time, and her role isn't specified.
Subjective:
CC (chief complaint): Elaine reports difficulty with remembering to take oral contraceptive pills regularly. She's experiencing heavy menstrual bleeding and is looking for effective contraception.
HPI: The primary concerns for Elaine are heavy menstrual bleeding and contraception management.
Current Medications: Elaine is currently taking Lamictal (lamotrigine) and Trileptal (oxcarbazepine) for her seizure disorder.
Allergies: Elaine reports no known drug allergies.
PMH: Elaine's medical history includes exercise-induced asthma, seizure disorder, and IBS. No surgical history except tonsillectomy as a child.
Soc & Substance Hx: Elaine does not smoke or use recreational drugs and does not consume alcohol. There is no specific information about her exercise routine or safety habits.
Fam Hx: Family history includes dementia, COPD, osteopenia, fibromyalgia, and skin cancer.
Surgical Hx: Only notable surgery is tonsillectomy in childhood.
Mental Hx: No history of mental illness.
Violence Hx: No history of violence reported.
Reproductive Hx: Elaine has been with three partners in the last year, including her current partner for two months. She reports heavy periods, and previous contraception includes oral contraceptive pills, which she stopped due to difficulty remembering to take them consistently.
ROS:
GENERAL: Normal vital signs, including pulse 68, BP 118/72, weight 148 lbs., and height 5'7". No significant changes from last year.
HEENT: WNL.
CARDIOVASCULAR: WNL.
RESPIRATORY: WNL, apart from exercise-induced asthma.
GASTROINTESTINAL: Reports of IBS.
GENITOURINARY: Reports of heavy menstrual bleeding.
NEUROLOGICAL: Seizure disorder, under control, with last seizure reported five years ago.
MUSCULOSKELETAL: WNL.
HEMATOLOGIC: No reports of anemia, bleeding, or bruising.
LYMPHATICS: WNL.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: WNL.
REPRODUCTIVE: No desire for future pregnancy. Interested in...…Elaine did mention her sister had an implant and experienced constant bleeding, so it's essential to discuss all potential side effects so she can make an informed decision.
Given her history of seizure disorder and the medications she takes, it is important to consult her neurologist before initiating a new contraceptive method (Kirkpatrick et al., 2022). Elaine's seizure disorder and the medications she takes for it could potentially interact with hormonal contraceptives. For instance, some anti-seizure medications can increase the breakdown of hormonal contraceptives in the body, reducing their effectiveness. Before starting a new contraceptive method, it would be beneficial to consult with her neurologist or a pharmacist to ensure that the chosen method will not interact negatively with her current medications or exacerbate her seizure disorder.
She should also be educated about the potential drug interactions between her seizure…
References
Hirth, J. M., Dinehart, E. E., Lin, Y. L., Kuo, Y. F., & Patel, P. R. (2021). Reasons why young women in the United States choose their contraceptive method. Journal of Women's Health, 30(1), 64-72.
Kirkpatrick, L., Van Cott, A. C., Kazmerski, T. M., & Bravender, T. (2022). Contraception and Reproductive Health Care for Adolescent and Young Adult Women with Epilepsy. The Journal of Pediatrics, 241, 229-236.
Mansour, D., Hofmann, A., & Gemzell-Danielsson, K. (2021). A review of clinical guidelines on the management of iron deficiency and iron-deficiency anemia in women with heavy menstrual bleeding. Advances in therapy, 38, 201-225.
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