unit4journal.docx

Name:  Jessica Dale

 Pt. Encounter Number: 2

Date: January 30, 2023

Age: 18

Sex: Female

SUBJECTIVE

CC: 

“I want to get on the pill before I go to college.”

HPI: 

18 yo Caucasian female presents to office seeking contraception. She is preparing to go away to college and would like to prevent pregnancy but is concerned about weight gain. She has friends who use contraception in a way that they do not have menses and she is interested in this as well, but she is concerned about the safety of this option. States she had unprotected vaginal sex with a male 1 year ago. Not currently sexually active or in a relationship. Onset of menses age 13. Reports regular menses once monthly lasting 6-7 days with normal flow. She reports lower back pain and cramping beginning the day prior to menses. She has treated these symptoms with Midol and heating pad with relief.

Medications: Midol as needed for cramping. Denies prescription medications.

Allergies: NKDA

Medication Intolerances: none noted

Past Medical History: denies

Chronic Illnesses/Major traumas denies

Hospitalizations/Surgeries: none

Preventative: Gardasil vaccination series completed as a teen

 TDAP 6 years ago

Family History

Mother: asthma

Father: basal cell carcinoma removal, HTN

Social History

She has completed high school and plans to transfer to University of Florida in a few weeks and will live in the dorms. Currently lives at home with her family and feels safe there. Denies use of alcohol or drugs although she admits that she has not ruled out the possibility of drinking once at college. Tried vaping once and felt sick, no further tobacco use. She has been sexually active in the past but is not currently. Not currently in a relationship.

ROS Student to ask each of these questions to the patient: “Have you had any…..”

General

Denies recent weight change but has concerns about weight gain with oral contraception use. Denies fever, chills, night sweats or fatigue.

Cardiovascular

Denies.

Skin

Denies any skin issues but reports recently beginning a new skin care routine.

Respiratory

Denies.

Eyes

Denies.

Gastrointestinal

Denies.

Ears

Denies.

Genitourinary/Gynecological

Denies urinary issues. Has not had PAP or pelvic exam.

Onset of menses age 13. 6-7 day cycle, normal flow. Back pain and cramping one day prior to onset.

Not currently sexually active but has been past. Has used condoms.

Has not tested for STI’s.

Nose/Mouth/Throat

Denies.

Musculoskeletal

Denies.

Breast

Denies

Neurological

Denies.

Heme/Lymph/Endo

Denies.

Psychiatric

Denies.

OBJECTIVE

Weight       125lbs   BMI 20.2

Temp 97.9

BP 112/62

Height 5’6”

Pulse 69 regular

Resp 16 pattern normal

General Appearance

Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.

Skin

Nose ring left nares. Acne noted along jaw line.

HEENT

Head is normocephalic, atraumatic. PERRLA. EOMs intact. Ears: Canals patent. Nose: Nasal mucosa pink. Neck: Supple. Full ROM; no lymphadenopathy. No thyromegaly or nodules. Oral mucosa, pink and moist. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. Capillary refills two seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs with wheezes bilaterally. Nonproductive cough noted.

Gastrointestinal

Abdomen soft, nontender. BS active in all the four quadrants. No hepatosplenomegaly. 

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary

Bladder is nondistended; no CVA tenderness. Speculum exam performed. No cervical lesions. No visible discharge or blood in vaginal vault. No vulvar lesions noted. Uterus anteverted, mobile and nontender. Adnexa palpable bilaterally, nontender. Rectal exam reveals no mass, good sphincter tone.

Musculoskeletal

Extremities atraumatic, no tenderness or deformity. Full ROM in all four extremities.

Neurological

Speech clear. Sensation intact. Judgement appropriate.

Psychiatric

Alert and oriented. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

***Beta quantitative HCG < 5mIL/ml

Urinalysis negative

Urine pregnancy test negative

KOH negative

NAAT negative

Assessment

· **Encounter for contraceptive management, High risk sexual behavior, Hormonal Acne

· Include at least three differential diagnoses

· Provide rationale for each differential diagnosis

· Final diagnosis ****Encounter for contraceptive agent, hormonal acne

· Pathophysiology of primary and rationale for choosing as final

Plan

· ******Educate on safe sex practices including condom use, follow up one year, start on continuous monophasic combined hormonal contraceptive pill, start on tetracycline antibiotic for hormonal acne.

· Medications

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Culture considerations

· Health promotion

· Referrals

· Follow up