Contraceptive Renewal

HISTORY:

Presents for a contraceptive renewal



Current contraception: ‍none ‍ for the last ‍ years

Satisfaction: ‍goodaveragepoor

Tolerance: ‍adverse effects

Adherence: ‍very goodaveragepoor, ‍norareoccasionalfrequent missed dose



Desire for pregnancy in the next year: ‍yesno

Sexual activity: ‍activeinactive

Condom use: ‍alwayssometimesno

History of STIs: ‍none ‍



Last Pap smear: ‍ ‍monthsyears ago ‍never

HPV vaccination: ‍up-to-dateincompleteunvaccinated

Last menstrual period: ‍ ‍daysweeksmonths ago

Menstrual cycles: ‍ days, ‍regularirregular

Menstrual symptoms: ‍nonepainheavy bleeding



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU



Contra-indications to estrogens:

‍thromboembolic disorders

‍smoking over 35 years of age

‍breast cancer

‍migraine with aura

‍migraine over 35 years of age

‍uncontrolled hypertension

‍cardiovascular disease

‍diabetes with vascular complications

‍antiphospholipid antibodies



Contra-indications to progesterone:

‍pregnancy suspected

‍undiagnosed genital bleeding

‍active liver disease



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Breasts: -R: ‍normal, -L: ‍normal

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Pelvic: vulva ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍no cervical motion tenderness



ASSESSMENT:

‍Contraception ‍appropriatelikelypossible



PLAN:

- Pregnancy test

- STI screening

- Pap smear

- ‍Oral contraceptives

- ‍Other contraceptives

- ‍Emergency contraception

- Counseling on proper use of contraceptive method

- Counseling on emergency contraception

- Counseling on condom use for STI prevention

- Follow-up in ‍ ‍monthsyears

- Return if side effects occur