Soap Note CC: “I need to start on birth control, I just don’t know which one to go on as there are so many to choose from.”

Name: MT

Date:12/3/19

Time: 0930

Encounter 2

Age: 32

Sex: Female

SUBJECTIVE

CC:

“I need to start on birth control, I just don’t know which one to go on as there are so many to choose from.”

HPI:

30 -year-old Asian American female that presents to the clinic requesting to start birth control.

Medication: (list with reason for med)

PT is not taking any medication currently

PMH: None

Allergies: Does not have any food or drug allergies

Medication Intolerances: None

Chronic Illnesses/Major traumas:

Patient denies any medical trauma

Chronic Health Problems: No known chronic health problems

Hospitalization/Surgeries: None

Family History: Mother Healthy. Father HTN. Sister Healthy. Brother autism

Social History:

Social history is negative for ETOH and she denies past or present illicit drug use. Denies present use of tobacco. States she does exercise regularly, and is not on a specific diet. Pt is currently in school for accounting.

ROS

General:

Patient denies weight change, fatigue, fever, chills, night sweats, energy level

Cardiovascular:

Denies any episodes of chest pain, palpitations, syncope or orthopnea.

Skin:

Denies any skin lesions.

Respiratory:

Patient denies dyspnea. Denies cough

Eyes:

Patient states no changes in vision, no blurred or double vision.

Gastrointestinal:

Patient denies any change in appetite, denies nausea and vomiting. denies any bowel changes

Ears:

No recent hearing loss, tinnitus, denies any ear discharge or pressure.

Genitourinary/Gynecological:

Patient denies any itching, burning or discharge

Last PAP: 9/11/18

Mammogram: 11/2/18

Pregnancy: G4P3

Not on any contraception, is currently sexually active. Has had one partner. No STD history.

LMP: 4/21/19

Nose/Mouth/Throat:

Denies any runny nose or discharge. Denies any difficulty swallowing or sore throat

Musculoskeletal:

Denies any weakness.

Breast: Denies any lumps or tenderness

Neurological:

Patient denies any syncope, seizures or weakness.

Heme/Lymph/Endo:

Denies any bruising, night sweats and swollen glands.

Psychiatric:

Denies anxiety or insomnia, denies suicidal ideations.

OBJECTIVE

Weight: 125 lbs

BMI: 21.5

Temp: 98.9

BP: 132/75

Height: 5’2”

Pulse: 83

Resp: 18

General Appearance:

Normotensive, Asian female sitting on exam table in no acute distress. Patient is well groomed. Cooperative with a pleasant affect.

Skin:

Warm and dry, intact. No rash, lesions noted.

HEENT:

Normocephalic, no lesions. Pupils equal, round, reactive to light. Tympanic membranes are gray, non-bulging with no erythematous. Mucosal pink and moist. Neck: No Jugular venous distention, no palpable masses.

Cardiovascular:

Regular rhythm, tachycardia, S1 and S2. No S3, S4, or murmurs, no rubs, no gallops.

Respiratory:

Clear breath sounds bilaterally. no labored breathing. No cough

Gastrointestinal:

Non-tender, hypoactive bowel sounds present in all 4 quadrants.

Genitourinary/Gynecological:

Bladder is non-distended; no CVA tenderness. External genetalia reveals coarse pubic hair in normal distribution; no lesions noted.

Musculoskeletal:

No edema. Peripheral pulses intact. Capillary refill is less than 2 seconds.

Neurological:

Speech is clear coherent. stable gait.

Psychiatric:

Patient is alert oriented to person, place, time and location. Well groomed.

Lab Tests

Urinalysis – pending results

Pregnancy test – negative

Specials Tests

N/A

Differential Diagnosis:

Z30.018 Encounter for initial prescription of other contraceptives

Plan/Therapeutics

Non-pharmacologic treatment: Watchful waiting

Pharmacologic treatment: Depo-Provera or DMPA is injected every 12 weeks which makes it an intermediate-acting contraceptive that is highly effective, estrogen-free and low maintenance option (Perry, 2014). Combination oral contraceptive pills are first line off-label therapy for women who experience heavy or prolonged bleeding, infrequent or painful menses, recurrent luteal phase ovarian cysts, family history of cancer, personal risk factors for endometrial cancer, acne, hirsutism, and polycystic ovary syndrome (Slomski, 2013). The use of the pill has a slightly higher failure rate than long-acting and injectable. 

Education: Patient education is geared towards signs and symptoms to seek medical attention for such as, changes in menstrual cycle, ongoing pelvic pain, abdominal fullness. Patient also needs education on injected contraceptives, needs to be followed up every 3 months. The use of condoms with every partner to decrease the chances of contracting an STD.

No referrals at this time.

The evaluation of this patient was very useful in my education and management of Gynecological disorders.