Dolores Sanchez is a 16 yo female|Health Case Study

History of Present Illness

Dolores Sanchez is a 16 yo female scheduled for a contraceptive visit. “I want to discuss birth control today. I have a boyfriend and have been using condoms for a while, but I want something more effective. Some of my friends use the shot and have gained weight.  Will the pill make me gain weight?” Dolores states that she has been having intercourse on an infrequent basis over the past year. Now she has a steady partner and is having intercourse approximately twice a week for the past two months. Dolores states that she is currently having a regular, normal period that started 3 days ago. Dolores goes on to say that although she has heard about birth control methods such as the implant and IUDs, her older sister uses the pill and likes the pill as a method. Dolores assumes that she, too, will do well with the pill.

Medical History

No hospitalizations, surgeries, or major medical problems. She has had all of the usual childhood immunizations: MMR, Hepatitis B, varicella, IPV, HIBPCV13, DTaP series as a child, and Tdap booster at age 11. She started the HPV series with the first dose given one year ago. She did not return for subsequent doses.
Family Medical HistoryMGM: 72 yo (breast cancer, treated with radiation) MGF: 73 yo (lung problems, smoker)PGM: 70 yo (hypercholesterolemia) PGF: Deceased at age 69 yo (MI) Mother: 40 yo (asthmatic, smoker)Father: 42 yo (HTN, hypercholesterolemia)Siblings: Two brothers, 14 yo and 12 yo; sister 18 yo (all healthy)

Social History

Smokes one-half pack per day. She had her first cigarette at age 13. Had smoked infrequently until last year when she began to smoke regularly with her friends. Is a sophomore in high school; enjoys school and maintains a B grade average. Is not involved in school sports other than physical education class twice a week. On yearbook committee. Lives at home with both parents. Works part-time in a convenience store. Denies drug use; occasional beer with friends. CAGE questions: Negative responses. Uses seatbelts. Denies history of intimate partner violence.


Occasional ibuprofen 400 mg for menstrual cramps

Allergies NKDA

Review of Systems 

General: alert, healthy-appearing young female

HEENT: Ear infections as a child but not since age 10; denies asthma, hay fever, frequent colds, nasal discharge, sinus problems; no dental problems, but does not have regular preventive dental care

Cardiovascular: No history of heart murmur or heart problems

Respiratory: Denies any difficulty with breathing, asthma, or bronchitis

Abdominal/gastrointestinal: Denies heartburn, abdominal pain, constipation, diarrhea, rectal bleeding; no history of liver or gallbladder disease

Genitourinary: Menarche, age 12; menses, regular 28- to 30- day cycles, lasting 5 days, describes flow as moderate for 3 days, lighter for 2 days; experiences cramping on day 1 of cycle for which she uses ibuprofen 400 mg 2 to 3 times a day for 1 day with relief of cramping; denies intermenstrual or postcoital bleeding or dyspareunia; first intercourse at age 15 ½; two sexual partners, infrequent intercourse until 2 months ago; no complaints of vaginal discharge, itching, burning, or urinary dysuria or frequency; LMP started 1 week ago, normal menses, has not had intercourse since LMP; is planning on becoming more sexually active with current partner

Neurological: Headache on first day of menses that is relieved by the ibuprofen; no other complaints of headaches, no history of migraines; no history of seizures

Endocrine: States she is fatigue on the three days a week that she works after school because she must stay up late to finish homework; is not fatigued if she has 8 hours of sleep at night; no history of diabetesMusculoskeletal: No complaint; no history of injuries, muscle pain, or joint pain

Physical ExaminationVital signs: Temperature 98.2 F; BP 120/62 mm HgHeight: 66 inches Weight: 160 lbs. BMI: 25.8

After reviewing the case and grading rubric, please answer the following:
1. Learning Issus (Before identifying your recommended Assessment and Plan, identify any learning issues that you believe are important for you to explore about this case):

2. Assessment (Please indicate the problems or issues you have identified that will guide your care [preferable in list form]):

3. Plan (Please list your plans for addressing each of the problems or issues in your assessment making sure to utilize references to support your plan)


Differential Diagnosis


10 (10.00%)

Lists 3 differential   Dx for the health issue




20 (20.00%)

Discusses the   pathophysiology of the most likely health issue presented.




15 (15.00%)

Presents the   cultural, ethical, and/or legal issue(s) and how it may conflict with the   patient care/health promotion




20 (20.00%)

Provides   patient-centered pharmacological and/or non-pharm solutions to the health   issue




15 (15.00%)

Provides a   comprehensive list of additional health services available and may be needed


Provider Implications


10 (10.00%)

Reflects on how the   cultural or ethical issue mirrors/contradicts your own beliefs and how this   may impact your care as a provider

Complete Answer:

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