Contraceptive Renewal

Age: ‍ years old

Gender: female



HISTORY:

Presents for a contraceptive renewal

Last visit was ‍ ‍months ago



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 ‍

STI risk factors: ‍none ‍

Last Pap smear: ‍ ‍monthsyears ago

HPV vaccination: ‍up-to-dateincompleteunvaccinated



Last menstrual period: ‍ ‍daysweeksmonths ago

Menstrual cycles: ‍ days, ‍regularirregular

Menstrual symptoms: ‍nonepainheavy bleeding



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, ‍apparent distress

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

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Breasts: ‍normal, ‍mass, ‍axillary adenopathy

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness





ASSESSMENT:

‍Contraception ‍appropriatelikelypossible





PLAN:

Investigations:

- Pregnancy test

- STI screening

- Pap smear

Treatments:

- ‍Oral contraceptives

- ‍Other contraceptives

- ‍Emergency contraception

- Counseling on proper use of contraceptive method

- Counseling on emergency contraception

- Counseling on condom use for STI prevention

Further care:

- Follow-up in ‍ ‍monthsyears

- Return if side effects occur