CC: prenatal revisit- SOAP 2

Constitutional: General Appearance: Well-appearing, well-groomed, bright affect. Appears stated age. Cooperative and answers questions appropriately.

Skin: Warm, dry, intact. No unusual bruising or suspicious lesions or moles.

HEENT: Head: normocephalic and atraumatic. Face: symmetric. Eyes: Sclera white, no

discharge. Conjunctiva pink.

Cardiovascular: Regular rate and rhythm, s1 and s2 present, no murmurs, rubs, or gallops.

Respiratory: Lungs CTA bilaterally. No rhonchi, rales, or wheezes.

Breasts Exam : B/L breast No change in the skin of the breast, no breast swelling, No retraction of the nipple. No deviation of the nipples. No abnormal secretion, No palpable masses bilaterally. No tenderness. No diffuse fibrous tissue.

Abdomen: Abdomen soft, non-distended, and non-tender. No CVA tenderness.

Pelvic Exam: External Genitalia: Hair distribution of normal female pattern. Vulva, labia majora, labia minora, and introitus are pink and moist without lesions or erythema. Perineum without lesions. No inguinal lymphadenopathy. Vagina: Walls pink and moist, rugae present, no lesions/tears, no odor, no discharge in the vaginal canal. Good tone. Cervix: Pink, smooth, mobile, without lesions, bleeding, or polyps. no discharge present. (Sureswab collected at this time).. Uterine: Uterus small, anteverted, midline, mobile, soft, non-tender. Negative CMT

Adnexae: No adnexal enlargement, tenderness, or masses palpated bilaterally. Wet Prep: Wet preps are not done at the clinical site. (based on age Wet test is not required )

Diagnostics:

1. Laboratory Tests:

· Urinalysis by dipstick: Urine protein negative, glucose negative, and leukocyte esterase negative.

· UA culture clear UPT Negative, CBE and pelvic exam WNL, PAP Smear collected, STD cultures collected

· A pelvic ultrasound performed: Multiple slices through the pelvis utilizing transvaginal approaches using 2D and 3D

· The uterus is Anteverted and has a Normal appearance.

· The uterus measures 7.15 x4.42 x3.7cm. The uterine volume= 37.59ml.

· There is no evidence of myomas. 3D construction shows a normal contour of the endometrial cavity and myometrium.

· The endometrial cavity has a Normal appearance and measures 9.51 mm.

· The cervix has a normal appearance. The cul de sac shows No fluid collections.

· The right ovary measures 4.52 x3.14 x1.95cm and has Multiple Follicles.

· The left ovary measures 3.3 x1.3 x1.43cm and has a normal appearance.

· No adnexal masses.

· Visit for gynecological exam without abnormal findings

· Encounter for contraceptive pill surveillance

· Medications:

· Loestrin Fe 1/20 1-20 mg-mcg tablet, take one tablet by mouth daily x 28 days

· Procedures: PAP Smear.

· Education:

Educated the patient that the first 21 tablets contained hormones (active pills).

And that the last seven tablets contain iron (inactive pills), during which a withdrawal bleed (similar to a monthly period) may occur.

Educated her to Swallow the tablet whole with water. It can be taken with or without food.

Missed Dose education provided:

· Missed one active pill: Take it as soon as you remember, even if that means taking two pills in one day. Continue with the pack as usual.

· Missed two consecutive active pills: Take two pills as soon as possible and then take two more pills the following day. Use backup contraception, such as condoms, for at least 7 days.

· Missed three or more active pills: Discard the current pack and start a new one immediately. Use backup contraception for 7 days.

· Missed placebo pills (iron pills): There is no need to worry. Continue taking the pills as scheduled.

· Educate on safe sex practices/condoms, discussed different forms of birth control, including pills, patches, injections, IUDs,

· Advised foreplay, lubrication, and change in sexual positions.

· Education on ACHES: Abdominal Pain, Chest Pain, Headaches, Eye Problems, Severe Leg Pain or Swelling that can be associated with contraceptives, and when to seek emergency care

· RTC in 3 months for OCP surveillance and 1 year for annual exam or PRN

Referral:

· PCP for health maintenance

· GI for occasional abdomen discomfort.