months, but they’re not ready for kids just yet. Adeline states that they have been in a monogamous sexual relationship for the past 2 years; their primary method of contraception was inconsistent use of male condoms. She is here today to be evaluated for the use of hormonal contraceptives. The patient states she began menses at age 14, with irregular cycles of 25–36 days in length. Her last menses was 2 weeks ago. The patient states she has heard
Adeline, a 24-year-old graduate student presents to her Family Medicine Clinic for contraceptive counseling. She and her fiancé, Josh, are planning to be married in approximately 3 months, but they’re not ready for kids just yet. Adeline states that they have been in a monogamous sexual relationship for the past 2 years; their primary method of contraception was inconsistent use of male condoms. She is here today to be evaluated for the use of hormonal contraceptives. The patient states she began menses at age 14, with irregular cycles of 25–36 days in length. Her last menses was 2 weeks ago. The patient states she has heard about contraceptive options that “keep you from having a period,” and she wants to know more about those options, and if they would be okay for her to try.
She has a history of migraine headaches without aura or focal neurologic symptoms, but it is well controlled for the past 6 months on prophylactic therapy.
Her mother is 52 years old, has HTN and osteoporosis. Her grandmother died from complications of breast cancer, which was diagnosed at age 60. Her father is 53 years old, has osteoarthritis, hypothyroidism, and hyperlipidemia. While her grandfather died at age 74 due to MI. She currently lives in a house on campus, which she rents with three other graduate students. Once she and Fritz are married, they plan to rent an apartment together until she finishes graduate school. She admits to occasional social use of tobacco and alcohol (“a few drinks and a couple of cigarettes at parties on the weekends”). Otherwise, she denies regular smoking or alcohol use during the week, and she denies illicit drug abuse.
Medications:
Propranolol LA 160 mg PO once daily for migraine prophylaxis
Naproxen 220 mg, one to two tablets PO Q 8 h PRN menstrual cramps
Allergies: NKDA
ROS:
Patient states she has not had a migraine for more than 6 months; however, prior to being placed on propranolol for migraine prophylaxis, she reported experiencing menstrual-related headaches in addition to frequent migraines.
Physical Examination:
Gen: WDWN female in NAD
VS: BP 116/74, P 66, RR 14, T 37°C; Wt 56 kg, Ht 5'6''
Skin: Mild facial acne
Breasts: Equal in size without nodularity or masses, nontender
Abd: Soft, NT, no masses or organomegaly
Genit/Rect: Normal vaginal exam w/o tenderness or masses
Laboratory Tests
Negative Pap smear and UPT
Impression
Young, generally healthy, sexually active female with history of migraine headache disorder that has been well controlled with prophylactic medication is requesting hormonal contraceptives for birth control.
PLANNING: This section is where the final treatment plan is given for each of the active problems as justified in the assessment.
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