SOAP Note For Birth Control Method Assignment

Patient Information       

                                                                                                                                        Patient initials: R.K       Age:21    Gender: female                 Race: Hispanic

S:

CC: “I need advice on various forms of contraception that will work for me.”

HPI: R.K, a 21-year-old Hispanic woman, presented at the clinic unaccompanied with the intention of seeking advice on the best contraceptive technique that would work best for her. She stated that she had suffered from migraines in the past two months, which had affected her vision, but the symptoms were well managed with Naratriptan. She stated that she had a 28-day period and denied any abnormal or excessive bleeding.

Medication; She is currently not on any medication. Reported taking naratriptan 1mg PO BID for migraine attack. SOAP Note For Birth Control Method Assignment

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PMH:

GYN: 13-year-old menarche Menstruation is regular and lasts 3 to 4 days; no contraception has been used. Denies any previous history of STIs or vaginitis.

Immunization: up to date: last mammogram 7/9/2021

PSH: none

Family history: no significant family history reported.

Allergies: NKDA

SHx: R.K is her mother’s only child, and she grew up in Sonoma, California. She is a final-year college student; she is single but had a child with one of her boyfriend’s when she was 18-year-old. She works part-time as a cashier in a nearby store. She denies ever using illicit substances in the past or in the present. Denies ever smoking or exercising. She lives in a safe neighbourhood with her mother and since they are not financially stable, she is not on a specific diet. Reports wearing seat whenever she drives.

ROS

General: Denies fevers, chills, weight changes, and night sweats

HEENT: denies loss of vision, no recent hearing loss, nosebleed, and post nasal drip.

Cardiovascular: Denies chest pain, heart murmur or galops.

Respiratory: Denies SOB, and chronic cough

GI: Reported decrease in appetite and nausea. Denies heartburn, vomiting, or diarrhea. SOAP Note For Birth Control Method Assignment

Msk: denies joint pain, and weakness

Neurologic: Denies dizziness, syncope, and muscle spasm. Reported instances of headache

Genitourinary: Denies vaginal itching or burning. LMP 24/6/22. G1p1

Psychiatric: Denies insomnia, homicidal ideation, and depression. R

Endocrine: Denies heat or cold intolerances.

Skin/lymph/heme: Denies changes in skin color or, rash.

O.

PE

VTS: BP 128/72 left arm, sitting using regular adult cuff. Wt.: 145lb Ht.: 5’4 T.: 37.1 RR: 20 P: 72 Sp02: 98%

General: A&Ox3, with no acute distress. Appear her stated age

HEENT; normocephalic and atraumatic. EOMI, PERRLA, no palpable masses.

Cardiovascular: RRR, S1, S2 head. no murmur, nor gallops

MSK: No oedema. Full range of motion noted in all joints.

Skin:  Intact without rashes. Normal texture.

Abdomen: Soft and non-tender. Bowel sounds are normoactive.

Pelvic: cervix non-tender, uterus anteflexed, and non-tender. Vagina pink without lesion. Ovaries non-tender without palpable masses.

Breast: soft and non-tender. No abnormal masses noted

Neuro:  Memory and thought process intact. Stable gait

Psychiatric: Oriented to place and time. Her insight and judgement are good. She is well groomed.

Assessment:

Diagnostic test and result

Hemoglobin test: used to detect whether the patient is at danger of thromboembolism (Huguelet et al.,2022)SOAP Note For Birth Control Method Assignment.

Cervical cytology is used to identify any abnormal cells in the cervix.

Screening for STDs: to determine if the patient has any STDs.

HCG test: to rule out pregnancy. Result negative

Diagnosis

Migraine with Aura

The patient complained of migraines. It is crucial to establish whether the migraine has an aura. This is because people who suffer migraine with aura are more likely to have a stroke if they use combined oral contraceptives (Carlton et al.,2018). If it is established that she has migraine with aura, it is recommended to prescribe progesterone-only contraception because estrogen in combination oral contraceptives is known to promote clots formation.

Plan

Lab test: Patient lipid profile need to be determined.

Medication: Depo-Provera IM for every three months or Minipril 1-tab OD for 28 days. Because she has had migraine with aura, a combined oral contraceptive is not recommended for her.

Patient education;

The patient must be educated on the various hormonal contraceptives available and why she should use one over the other. She must be educated about the hazards of taking oestrogen-containing oral contraceptives to those suffering from migraine with aura. She must be informed on multiple routes of administering various hormonal contraceptives, such as implants, injectables, and oral contraceptives. Minipril, a progestin-only contraceptive medication, is recommended in such cases. If she chooses to take oral contraceptives, she must be reminded the significance of persistence. If the patient is worried about taking daily medications, injectables are an option. Hormonal contraceptives such as depot medroxyprogesterone acetate (DMPA) 150mg/ml IM, an injectable progestin, are a safe option for her.

While these choices are effective in her scenario, they do not protect against STDs, thus she must be urged to use a condom (Sathyamala et al.,2020)SOAP Note For Birth Control Method Assignment. Since hormonal contraception has a number of negative side effects, some such as   bloody coughing or chest pain, needs medical attention. The patient should be advised on the need of modifying her lifestyle, which includes exercising twice a week and eating a nutritional diet rich in fruits and vegetables. The patient should be advised about the significance of routine safety screening.

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References

Carlton, C., Banks, M., & Sundararajan, S. (2018). Oral contraceptives and ischemic stroke risk. Stroke, 49(4), e157-e159.

Sathyamala, C. (2020). Depo-Provera and HIV Transmission: WHO to Trust?. Different Takes, 95, 1-6.

Huguelet, P., Alaniz, V., Scott, S., Buyers, E., & Laurin, J. (2022). Evaluation and management of acute abnormal uterine bleeding in adolescents: oral contraceptive pill taper versus single-dose therapy, a pilot study. Journal of Paediatric and Adolescent Gynaecology, 35(2), 201. SOAP Note For Birth Control Method Assignment