According to Van Maanen, it is during the introduction stage…
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Accоrding tо Vаn Mааnen, it is during the intrоduction stage that the officer adjusts to the reality of police work.
Belоw is а cоpy оf the informаtion provided to you аs supplement to the door chart: Door Chart/Note & Learner Instruction Setting (place/time) OB/GYN Office, scheduled appointment Arrived via private car Patient Name: Reyna Castellano Age: 35 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: 120/82 Respiratory Rate: 16 breaths per min Pulse ox: 99% on RA Weight: 130 lb / 59 kg Height: 5’5” (65”) / 165 cm BMI: 21.6 Instructions to Learners: NOTE: The information provided below is from a previous encounter from two days ago by a different provider (from pt’s initial visit, with testing). All results returned as normal, so pt is here to discuss birth control options. OBJECTIVES: Review the provided patient history below.Revisit and confirm all details obtained from the recent visit that are relevant to birth control selection with the patient during this encounter. Develop and communicate a treatment plan and provide corresponding education on family planning with the patient. OTHER INSTRUCTIONS: 20 min patient encounter – with 5 min warning DO NOT COMPLETE A PHYSICAL EXAM. Be sure to discuss your reasoning/justification for your proposed treatment to the patient (in order to receive full credit). Patient History: HPI: Reyna Castellano is a 35 y/o F who presents for discussion of family planning/ birth control, stating “I’m here to talk about birth control”. She reports that her situation is unusual because she was recently married (4 months ago) and planning to have children soon, but was unexpectedly diagnosed with Stage IIa breast cancer 2 weeks ago. She reports that she and her partner wanted to begin having children as soon as possible until this occurred. This was discovered and recently diagnosed after she found a lump in her R breast a few weeks ago. She subsequently underwent biopsy just over 2 weeks ago. She is now due to begin treatment for her breast CA next week and has multiple follow up visits scheduled in the coming weeks with her surgical oncologist. She confirmed having a diagnostic mammogram, ultrasound and biopsy just over 2 weeks ago which confirmed breast cancer. As a requirement of her treatment, will be following up with a fertility specialist next month and was encouraged to speak about routine pregnancy prevention/contraception options today ahead of that appointment. She and her husband desire 1-2 children in the future after she is treated for her breast cancer. Until treatment is complete, they would like to ensure no unintentional pregnancy as she is expected to be taking medication or treatment that could be harmful to a developing baby. She reports no prior pregnancies. She reports her LMP was 8 days ago. She reports no abnormal bleeding between periods. She denies frequent spotting, pain with intercourse, or pelvic pain otherwise. Menstrual periods are reported to be 28-30 days in length, with typical bleeding occurring for an average of 4 days. 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. Past Medical History: -Stage IIA Breast Cancer (ER+/PR+, HER2-negative) - Found as a solitary 2.5cm tumor in the R breast with no nodal involvement and no metastasis. -Asthma (mild, intermittent type) (diagnosed in childhood) -Seasonal allergies (primarily related to certain grass and tree pollen) OB-GYN History: Menarche at 14 yrs old. G0P0. No hx of STI/STD. No hx of abnormal pap smear, with her most recent pap smear being last year. No abnormal findings at that time. No reported atypical cells at any time. Hospitalizations: No hospitalizations reported Surgical History: Recent breast biopsy only (approx 2 weeks ago), no other surgeries reported Screening/Preventive (if relevant): Pt is up-to-date on recommended, age-appropriate vaccines, including COVID, influenza, Tdap, as well as the HPV vaccine series. Medications (Prescription, Over the Counter, Supplements): -Albuterol MDI inhaler - 90mcg/actuation - 1-2 puffs q4-6 hrs PRN asthma symptoms (uses approx 1x/week) -Cetirizine (Zyrtec) 10mg PO daily -No breast cancer medication or treatment started yet, but pt reports she is due to begin next week (names of treatment medications / modalities not yet known) Allergies (e.g. environmental, food, medication and reaction): No known medical allergies Family Medical History: ● Father: alive, 62 years old. Known hx of hyperlipidemia and obesity. ● Mother: alive, 63 years old. Known hx of hypertension, and Type 2 diabetes. ● Brother: alive, age 32. Hx of PTSD (military related) No known genetic disorders in the family. No known hx of breast, ovarian, or other types of cancer in the family. 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: Renting an apartment with her husband just south of La Jolla Occupation Lawyer (tax law) Leisure Activities Volleyball, hiking, mah jong Diet Pescatarian Exercise Pilates 2-3x per week Running 1-2x per week Volleyball 1x per week Religious Practices Christian (Presbyterian) Sleep Averages 7 hours of sleep per night Sexual History Sexually active with her husband only No known hx of STI/STDs 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 Physical Exam: Gen: Pt is a well-developed, well-nourished 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 quadrants Extremities: No edema, swelling, or erythema. No palpable cords. 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 This patient went home after the most recent office visit awaiting the pending results of her diagnostic tests to determine next steps in her care, which is the reason for her visit today. ***END OF CASE INFORMATION***
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