This area is informational only. Please see the next questio…
This area is informational only. Please see the next question below for the prompt and task associated with this OSCE. Below is a copy of the information provided to you as supplement to the door chart: Door Chart Setting (place/time) OB/GYN Office, scheduled appointment Arrived via private car Patient Name: Bertina Rojas Age: 39 y/o Chief Complaint: “I’m here to talk about birth control” Vital Signs: (if applicable) Temperature: 98.5*F/ 37*C Heart Rate: 78 beats per min Blood Pressure: 150/96 Respiratory Rate: 18 breaths per min Pulse ox: 99% on RA Weight: 185 lb / 84 kg Height: 5’5” (65”) / 165 cm BMI: 30.8 Patient History: HPI: Bertina Rojas is a 39 y/o F who presents for discussion of family planning/ birth control, stating “I’m here to talk about birth control”. She shares that desires to change methods of birth control because she does not wish to have any more children. She reports dissatisfaction and concern with her husband’s current usage of condoms and withdrawal method, fearing unintentional pregnancy. She is hopeful that she can use an oral birth control, if possible, but is open to other options. She reports that prior to attempting to have children, she had an IUD for a long time that was removed when attempting to have children (approx 9 years ago). Prior to that, she was using oral birth control pills (she is unsure of which type she used, however). She and her husband desire no further pregnancy. She reports 1 prior pregnancy with 2 children – a set of twins that were c-section delivery after undergoing in-vitro fertilization (IVF) approximately 7 years ago. She reports her LMP was 8 days ago. She reports occasional cramping and heavy bleeding with her period, noting that this only happens 3-4 times per year. She denies frequent spotting, pain with intercourse, or pelvic pain otherwise. Additionally, the pt denies unusual weight changes, dysuria, hematuria, or change in urinary frequency. She denies any unusual vaginal discharge or bleeding at this time. Pt reported taking a pregnancy test this morning, which was negative. Illnesses/Injuries: -Hypertension -Type 2 Diabetes Mellitus -Migraine-type headaches with aura (pt reports approximately 1 per month, for which she uses abortive medication treatment) -Hypertriglyceridemia OB-GYN History: Menarche 14 yrs old. G1P2. Pt and her husband initially had difficulty conceiving their first child, so they underwent IVF and had a set of fraternal twins (one girl, one boy). No hx of STI/STD. No hx of abnormal pap smear results, with her most recent pap smear being last year. No abnormal findings at that time. No reported atypical cells at any time. Menstrual periods are reported to be 28-30 days in length, with typical bleeding occurring for an average of 5 days. Hospitalizations: For the birth of her two children (via C-section) – 7 years ago No other hospitalizations reported Surgical History: C-section delivery of twins – 7 years ago Screening/Preventive (if relevant): Pt is up-to-date on recommended, age-appropriate vaccines, including COVID, influenza, Tdap. Pt states she never completed the HPV vaccine series, however. Medications (Prescription, Over the Counter, Supplements): -Lisinopril 10mg PO daily -Metformin 1000mg PO BID -Omega-3 Fish Oil 1000mg PO BID -Zolmitriptan 5 mg – single dose intranasally once at onset of migraine (last taken 2 weeks ago) -Naproxen 500mg PO q12 hrs PRN migraine headache (last taken 2 weeks ago) Allergies (e.g. environmental, food, medication and reaction): No known medical allergies Family Medical History: ● Father: alive, 68 years old. Known hx of hyperlipidemia and obesity. ● Mother: alive, 67 years old. Known hx of hypertension, obesity, and Type 2 diabetes. ● Sister: alive, age 34. Hx of depression, being overweight, and diabetes ● Children (two which were born as fraternal twins after IVF): Son, age 7 alive and well; Daughter, age 7 alive and well. Social History: Substance Use (past and present) Drug Use: Denies recreational or illicit drugs. Denies any past drug use. Tobacco Use: Pt denies tobacco or vape use. Alcohol Use: Rarely has a glass of wine on the weekends with her husband. Home Environment: Lives in a single-story home with her husband (of 10 years) and two children in El Cajon Occupation Supply chain manager for ALDI grocery stores. She works remotely from home. Leisure Activities Gardening, knitting, taking her kids to the local parks and beach. Diet No specific diet followed. Eats quick microwave meals, and sometimes fast food often due to her busy schedule. Exercise Walks 15-30 minutes around her neighborhood up to 3 times per week Religious Practices Catholic Sleep Averages 6-7 hours of sleep per night Sexual History Sexually active with her husband only since being married (10 years ago) Laboratory Orders: -b-HCG / urine pregnancy testing – Result: Negative -Urinalysis – Result: Unremarkable / within normal limits -STI testing (gonorrhea, chlamydia, Wet mount- yeast/BV, trichomoniasis, HIV, RPR) – Result: All tests were negative / unremarkable -Finger stick (random) plasma glucose – Result: 190 mg/dL Physical Exam: General: Pt is a well-developed, well-nourished, obese appearing female. Pt is pleasant with normal affect, alert and oriented appropriately. Cardiac: RRR, S1/S2, no murmurs Pulm: CTAB, no crackling, wheezing, rales Abdomen: Soft, nontender, +BS X 4 Extremities: No edema, swelling, or erythema. No palpable cords, negative Homan’s bilaterally. Pelvic Exam: Normal-appearing cervix without friability, lesions, discharge or blood at cervical os; no cervical motion tenderness. Anteverted uterus, no adnexal masses or tenderness noted on bimanual exam. Uterus normal size, shape, and mobility; non-tender. External genitalia: Normal hair distribution; no lesions or masses Vagina: Pink, moist, well rugated; no blood or abnormal discharge present ***END OF CASE INFORMATION***