Subjective (S):
Identifying Data:
Intitals: A.M.
Age: 24
Race: Caucasian
Gender: Female
Marital Status: Single
Chief Complaint (CC): Patient states that she “needs her pap and refill on her birth
control.”
History of Present Illness (HPI): Patient is a health 24 year old white female with no
known medical history. Patient has had her first pap smear when she was 19 years old.
Previous pap was done in September of 2012 and was normal. She admits to only have one
male sexual partner with whom she uses condoms approximately 75% of sexual
encounters. Patient states that he is her only lifetime partner.
Past Medical History (PMH):
·
Allergies: NKDA
·
Current medications: Tri Sprintec, one tab daily
·
Age/health status: 24 years
·
Appropriate immunization status: Up to date on all vaccines; Patient would like to
receive FLU vaccine today as she receives it yearly. Refuses HPV vaccine.
·
Previous screening tests result: Normal pap smear in 2012. Patient’s mother was
diagnosed with breast cancer at age 41, therefore mammograms are recommended to
begin at ate 31.
·
Dates of illnesses during childhood: N/A
·
Major adult illnesses: No medical history
·
Injuries: N/A
·
Hospitalizations: No hospitalizations.
·
Surgeries: N/A
Family History (FH): Patients father has a history of GERD and gastric ulcers. Mother has a
history of breast cancer (diagnosed at age 41), for which she underwent a lumpectomy,
radiation therapy and is currently taking an aromatase inhibitor. Patient denies any other
major family history.
Social History (SH): Patient is a single female who is currently attending school to obtain
her Bachelor’s degree in Business. She currently works at Gulf State Park and states that it
is a low stress job. Normal diet, exercises rarely. Denies the use of alcohol, tobacco or illicit
drugs.
Review of Systems (ROS):
1.
Constitutional symptoms- Patient denies fatigue, fever, chills, malaise, night sweats,
unexplained weight loss or weight gain, loss of appetite, difficulty sleeping.
2.
Eyes- Patient denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma,
peripheral visual changes, and dry eyes. Patient states she does wear contacts. Date of last
eye exam was August of 2014.
3.
Ears, nose, mouth, and throat- Patient denies vertigo, headaches, sinus problems,
epistaxis, hoarseness, dental problems, oral lesions, hearing loss or changes, nasal
congestion.
4.
Cardiovascular- Patient states she rarely exercises. Patient denies any history of heart
murmur, chest pain, palpitations, dyspnea, activity intolerance, varicose veins, edema.
5.
Respiratory- Patient denies cough, SOB on exertion, difficulty breathing, wheezing,
pain on inspiration, exposure to passive smoke, history of respiratory infections, exposure
to TB, hemoptysis. Patient states she has never had a chest x-ray. Her last TB skin test was
done in January 2012 for work and it was negative.
6.
Gastrointestinal- Patient denies dysphagia, reflux, pyrosis, loss of appetite, bloating,
nausea, vomiting, diarrhea, constipation, hematemesis, abdominal or epigastric pain,
hematochezia, change in bowel habits, food intolerance, flatulence, hemorrhoids.
7.
Genitourinary- She denies dysuria, heavy bleeding and incontinence. Date of LMP was
1 week ago. Had first period at age 14, has had regular monlthy periods. Admits to sexual
conduct with only one partner.
8.
Musculoskeletal- Patient denies joint pain, swelling, muscle pain or cramps, neck pain
or stiffness, changes in ROM.
9.
Integumentary- states uses sunscreen when in the sun. Denies changes in skin, rash,
itching, nail deformity, hair loss, moles, open areas, or bruising. Breast: denies lumps,
pain, discharge, or dimpling during self breast exam.
10. Neurologic- Patient denies transient weakness, numbness, muscular weakness,
tingling, memory difficulties, involuntary movements or tremors, syncope, stroke, seizures,
paresthesias.
11. Psychiatric- Patient denies nightmares, mood changes, anxiety, depression,
nervousness, insomnia, suicidal thoughts, exposure to violence, or excessive anger.
12. Endocrine- Patient denies thyroid problems, cold or heat intolerance, polydipsia,
polyphagia, polyuria, changes in skin, hair or nail texture, unexplained change in weight,
changes in facial or body hair, changes in hat or glove size, use of hormonal therapy.
13. Hematologic/lymphatic- Patient denies unusual bleeding or bruising, lymph node
enlargement or tenderness, fatigue, history of anemia, blood transfusions.
14. Allergic/immunologic- Patient denies seasonal allergies, allergy testing, exposure to
blood or body fluids, use of steroids, or immunosuppression in self or family.
OBJECTIVE DATA (O):
1.
Constitutional- VS: Temp- 98.8, BP- 110/67, HR- 68 Height- 5’7”, Weight- 178
lbs; General Appearance: healthy-appearing, well-nourished, and well-developed . Level of
Distress: NAD. Ambulation: ambulating normally.
2.
Eyes- sclerae white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally. Extraocular
movements intact.
3.
Ear, Nose, Throat-
Ears: external appearance normal-no lesions, redness, or swelling; on otoscopic exam
tympanic membranes clear. Hearing is intact.
Nose: appearance of nose normal with no mucous, inflammation or lesions present. Nares
patent. Septum is midline.
Mouth: pink, moist mucous membranes. No missing or decayed teeth.
Throat: no inflammation or lesions present. Tonsils WNL- no erythema, ulcers, masses,
exudate, inflammation.
4.
Cardiovascular- S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs
Carotid Arteries: normal pulses bilaterally, no bruits present
Pedal Pulses: 2+ bilaterally
Extremities: no cyanosis, clubbing, or edema, less than 2 second refill noted
5.
Respiratory- Even and unlabored. Clear to auscultation bilaterally without wheezes,
rales, or rhonchi.
6.
Gastrointestinal- abdomen soft and nontender to palpation, nondistended. Negative
Murphy’s sign. No rigidity or guarding, no masses present, BS present in all 4 quadrants
7.
Genitourinary- No bladder tenderness upon palpation, no distention noted. External
genitalia normal, no gross lesions or lacerations. Vagina shows healthy, pink mucosa, no
gross lesions, white discharge noted. Cervix shows no lesions. Wet prep has normal
results.
8.
Musculoskeletal- Normal ROM, joint stability normal in all extremities, no tenderness
to palpation. No scoliosis noted.
9.
Integument/lymphatic-
Inspection: No scaling, redness or breaks on neck, or arms, or trunk. Skin warm, dry and
intact with good skin turgor.
General palpation: no skin or subcutaneous tissue masses present, no tenderness, skin
turgor normal
Lower Extremities: no rash, lesion, or discoloration present
Upper Extremities: no rash, lesion, or discoloration present
10. Neurologic- Grossly alert and oriented x3, communication ability within normal limits,
attention and concentration normal. Sensation intact to light touch, gait within normal
limits
11. Psychiatric- Judgment and insight intact, rate of thoughts normal and logical. Pleasant,
calm, and cooperative. Patient appears to be happy/content.
12. Hematologic/immunologic- Lymph nodes not palpable, no tenderness or masses
present, no bruising or bleeding noted.
Diagnostic Testing:
-
Pap Smear: Pending
-
Wet Prep: Normal
Assessment (A):
1.
Pap Smear
V72.31 Routine gynecological exam with pap
Patient states that she needs her routine pap smear and after reviewing the patient’s
records, it is noted that this is appropriate. Patient is sexually active and on oral
contraceptives, therefore pap smears are recommended.
2.
Family planning
V25.09 Counseling and advice on contraceptive management
Patient has requested a refill on her oral contraceptives and has discussed her usage of
back up birth control when she occasionally misses a dose of medication.
Plan (P):
1.
Pap smear was performed with no difficulties. Sample was sent to LabCorp; results
pending. Patient is aware that she will receive results in the mail at home. Patient will be
contacted by the clinic if it is abnormal.
2.
Tri Sprintec, 1 pill PO daily, disp #1, 11 refills; Encourage patient to continue to use a
backup form of birth control is OCs are missed. Reiterate the importance of taking this
medication as directed and maintaining only one sexual partner.
Medication Profile: Tri Sprintec
o Indication: Prevention of pregnancy. Treatment of moderate acne vulgaris in females
≥15 yrs of age who have no known contraindication to oral contraceptive therapy, desire
oral contraceptive for birth control, and have achieved menarche.
o MOA: Combination oral contraceptive; acts by suppressing gonadotropins, primarily
inhibiting ovulation, and causing other alterations, including changes in the cervical mucus
(increases difficulty of sperm entry into the uterus) and the endometrium (reduces
likelihood of implantation). Acne: not established; increases sex hormone-binding globulin
and decreases free testosterone.
o Dosage: Three different doses in package that are taken in a specific order. Tri-Sprintec
(norgestimate and ethinyl estradiol tablets) 0.18 mg/0.035 mg are gray, round, unscored
tablets debossed with stylized b on one side and 985 on the other side; 0.215 mg/0.035
mg are light blue, round, unscored tablets debossed with stylized b on one side and 986
on the other side; 0.25 mg/0.035 mg are blue, round, unscored tablets debossed with
stylized b on one side and 987 on the other side.
o Brand, generic: Tri-Sprintec; norgestimate and ethinyl estradiol
o Cost for 3 pharmacies: WalMart ($4); Target ($0); Coastal Pharmacy ($9)
o Cost for 30 day supply: Free to $10
Outside testing: Pap Smear, pending
Follow up: 1 year and PRN
Referral: N/A
Patient education:
-
Oral contraceptives can cause DVTs. Do not smoke while taking OCs, as it increases
the risk of DVT.
-
Certain medications decrease the effectiveness of OCs. If you are placed on a new
medication, ensure that interactions are checked.
-
If you miss a dose, take that dose as soon as possible. If two doses are missed, take
two pills immediately, then continue taking one pill daily. If this occurs, use a form of back
up birth control for up to 7 days.
-
The use of OCs do not prevent against the transmission of HIV, AIDS or other STDs
-
Begin self breast exams on a monthly basis, especially with 1st degree relative history
of breast cancer.