Intrauterine Device Insertion
Age: years old
Gender: female
HISTORY:
Presents for intrauterine device
Current contraception: for the last years
Reason for IUD:
Last menstrual period: ago
Menstrual cycles: days,
Menstrual symptoms:
G P A
Desire for pregnancy in the next year:
Sexual activity: , partners,
Condom use:
History of STIs:
STI risk factors:
Last Pap smear: ago
HPV vaccination:
Contra-indications:
- Pregnancy
- Active PID or high PID risk
- Postpartum endometritis (<3 months)
- Recent septic abortion (<3 months)
- Uterine anomalies/fibroids distorting the cavity
- Progestin-sensitive cancers (e.g., breast)
- Unexplained vaginal bleeding
- Acute viral hepatitis or severe cirrhosis
- Known uterine or cervical neoplasia
EXAM:
General appearance: ,
Abdomen: , , , , bowel sounds , ,
Pelvic:
- External genitalia: , ,
- Vagina: , , discharge ,
- Cervix: , ,
- Bimanual exam: , uterus , adnexa ,
- Tests performed: , , pH , KOH sniff test
-
ASSESSMENT:
Intrauterine device insertion
PLAN:
Investigations:
- Pregnancy test prior to insertion
- STI screening prior to insertion
IUD Insertion:
- Type:
- Consent: informed of potential risks including perforation, expulsion, or infection, benefits of long-term contraception discussed, consent obtained
- Preparation: cervix cleaned with
- Anesthesia: with cc of
- Procedure: Uterine depth measured at cm, IUD inserted, strings trimmed to cm
- Tolerance:
- Instructions: expect some spotting or mild cramping initially, check strings monthly, use backup contraception for the first week
Further care:
- Return if abdominal pain, fever, or if the strings can no longer be felt
- Follow-up: Return in weeks or if complications/concerns arise
HISTORY: EXAM: Pelvic: ASSESSMENT: PLAN: