CC “discuss contraceptive options.”
HPI: 38-year-old female presents to the office to discuss contraceptive management options. She is a G5P5006. She denies wanting anymore children, but her partner has never fathered a child. She has a history of migraines. She is currently not using any form of contraceptive.
Current Medications: Vitamin C
PMHx: Positive for exercise-induced asthma, migraines, and IBS. Surgeries: Tonsillectomy. Hospitalizations: childbirth.
Soc Hx: Denies use of alcohol, tobacco, and recreational drugs. She is in a relationship with new partner who does not have children.
Fam Hx: Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Elaine has one older sister with no medical problems and one younger brother with no reported medical problems.
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Shortness of breath with exercise. Denies cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, or vomiting. Positive for occasional abdominal pain and diarrhea due to IBS. Denies abdominal pain and diarrhea today.
GENITOURINARY: Denies burning on urination. Last menstrual period: unknown.
NEUROLOGICAL: Positive for migraines. Denies dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: History of exercise-induced asthma. Denies history of hives, eczema or rhinitis.
VS: Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68
GENERAL APPEARANCE: alert, in no acute distress.
HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctivae are clear without exudates or hemorrhage. Ears: Hearing intact. Nose: Nares patent bilaterally. Throat/Mouth: Oral mucosa pink and moist.
NECK: Supple without adenopathy
CARDIOVASCULAR: S1 and S2 heart sounds. No murmur or abnormal heart sounds auscultated. Apical pulse 2+. Radial pulses 2+ bilaterally.
RESPIRATORY: Lung sounds clear in all lobes.
BREAST: Soft, fibrocystic changes bilaterally, without masses, dimpling or discharge.
ABDOMEN: Bowel sounds present in all quadrants. Soft, no tenderness noted.
VVBSU: 1st degree cystocele
CERVIX: Firm, smooth, parous, without CMT.
UTERUS: RV, mobile, non-tender, approximately 10 cm.
ADNEXA: Without masses or tenderness
Diagnostic results: Urine HCG test, Pelvic exam, breast exam, PAP smear (if due), STI testing if requested.
1. Encounter for other general counseling and advice on contraception-This is a good differential diagnosis, if the patient only wants to discuss contraceptive management today and take time to decide which one she prefers. She may also want to talk to her partner prior to starting. I would highly suggest contraceptive management, since she has a cystocele and she does not want more children, but her partner does. Dietz, Shek, and Low’s (2022) study revealed that women with a cystocele are more likely to have a partial avulsion during pregnancy.
2. Cystocele-This is a secondary diagnosis because it was found on exam. She needs to be referred to pelvic floor therapy.
3. Encounter for contraceptive management-This is a great differential diagnosis, because it covers a variety of contraceptive options and she wanted to start contraceptives. I would highly recommend the use of contraceptives to avoid pregnancy until the cystocele improves. Also, her partner may try to persuade her to have another baby when she is not ready for one right now. Since she has migraines and I do not know her migraine symptoms, I would recommend starting progesterone-only oral contraceptives, DEPO shot, or an IUD. Lodi and Advani (2018) state, “the association between hormonal contraception and stroke risk is estrogen dose-dependent and use of combined hormonal contraception increases the risk of stroke in women with any type of migraine”.
4. Counseling and instruction in natural family planning to avoid pregnancy-This would be a differential diagnosis if the patient does not want to use any type of contraceptive, but instead wants to do natural family planning. Hassoun (2018) states that this is the least effective method of preventing pregnancy and requires extensive education.
5. Malposition of uterus-This could be a differential diagnosis because her uterus is RV. She would benefit from pelvic floor therapy if she is experiencing any pain or discomfort.
Encounter for other general counseling and advice on contraception -Contraceptive options discussed in detail. Patient advised to avoid pregnancy at least until cystocele improves. Progesterone only oral contraceptives, DEPO shot, and IUD discussed as options for birth control due to migraines. Patient would like to think contraceptive options over at home. Will call when she decides. Discussed starting Norethisterone 5mg tablets 1 tab once a day for 28 days, Depo shot every 3 months, or Mirena IUD insertion every 5 years. RTC in 2 weeks for encounter for contraceptive management or sooner if needed.
Cystocele- Patient advised to start pelvic floor therapy due to cystocele. Referred to pelvic floor therapy. Patient advised to avoid pregnancy at least until cystocele improves.
Malposition of Uterus-Start pelvic floor therapy. Referral sent to pelvic floor therapist.