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Belоw is а cоpy оf the informаtion provided to you аs supplement to the door chart: Patient Summary / Door Chart Setting (place/time) OB/GYN Office Arrived via private car Patient Name: Bernadette King Age: 40 y/o Chief Complaint: “I’m here to talk about my birth control options.” Vital Signs: (if applicable) Temperature: 98.8oF/ 37.1oC Heart Rate: 80 beats per min Blood Pressure: 126/82 Respiratory Rate: 15 breaths per min Pulse ox: 99% on RA Weight: 178 lb / 81 kg Height: 5’7” (67”) / 170 cm BMI: 27.9 Patient Case History: HPI: Bernadette King is a 40 y/o F who presents for discussion of family planning/ birth control, stating “I’m here to talk about my birth control options.”She shares that she recently completed a divorce with her husband of 15 years, recently moved to San Diego and wishes to begin a new sexual relationship with a new partner in the near future. Her prior partner had a vasectomy, so she was not using birth control for the last 8 years and she would like to know what birth control options are available to her at this time. She desires no further pregnancy. She reports two prior pregnancies, one by vaginal delivery and one by c-section. She reports her LMP was 1 week ago. She reports intermittent dysmenorrhea and menstrual-relating cramping with spotting between periods over the last few years. She was told by her prior OB-GYN provider that she had “fibroids” after undergoing an ultrasound 2 years ago. No reported dysuria, hematuria, or change in urinary frequency reported. She denies any abnormal vaginal discharge or bleeding at this time. She denies any other symptoms currently. She reports that prior to her marriage, she had an IUD at one time and prior to that, she was using oral birth control pills (she is unsure which kind). She denies hx of abnormal Pap smear in the past. Pt reported taking a pregnancy test this morning, which was negative. Illnesses/Injuries: -Depression (diagnosed during the process of her divorce recently) -Seasonal allergies -History of large subserosal, non-cavity distorting, uterine fibroid diagnosed 2 years ago by ultrasound. Pt has not taken specific further action on this since diagnosis. OB-GYN History: Menarche 13 yrs old. G2P2. The first child was spontaneous vaginal delivery and the second child was c-section birth due to breach position of the baby. No hx of STI/STD (except HPV, as noted below). One pap smear resulted in +HPV (subtype 16) testing, with her most recent pap smear being last year. No reported atypical cells at any time. Menstrual periods are reported to vary and have been 22-32 days in length as of lately. She reports spontaneous interval bleeding at times between periods within the last few years and cramping prior to menses over the last 3-4 years. Hospitalizations: For the birth of two children only (8 and 9 years ago) Surgical History: C-section for second child (8 years ago) Screening/Preventive (if relevant): Pt is up-to-date on recommended, age-appropriate vaccines including COVID, influenza, Tdap. Pt states she was never offered the HPV vaccine. Medications (Prescription, Over the Counter, Supplements): -Citalopram 20 mg PO daily -Zyrtec 10 mg PO PRN -EpiPen (adult) – for use if signs/symptoms of anaphylaxis develop or exposure to allergen occurs (pt has not used this in over 5 years) Allergies (e.g. environmental, food, medication and reaction): -Latex (hx of anaphylaxis when exposed) -Bee stings (hx of anaphylaxis with bee stings) Family Medical History: ● Father: alive, 75 years old. Known hx of hypertension, DM, and obesity. ● Mother: alive, 74 years old. Known hx of HTN, uterine fibroids. ● Sister: alive and well, age 34 ● Brother: alive and well, age 38 ● Children (two): Son, age 8 alive and well; Daughter, age 9 alive, hx of ADHD, otherwise well. Social History: Substance Use (past and present) Drug Use: Does not use any recreational or illicit drugs. Denies any past drug use. Tobacco Use: Pt reports use of cigarettes, typically for stress relief and she has increased use over the last year in the setting of her divorce. On average, pt smokes 1 pack of cigarettes per week for the last 10 years. Alcohol Use: Does not drink alcohol. Home Environment Just moved to San Diego area (La Mesa) 3 months ago. Living in a rental home with her kids. Occupation Remote IT customer service work for Cisco. She works from home. Leisure Activities Gardening, taking her kids to the local parks and beach Diet No specific diet followed. Eats fast food often due to her busy schedule. Exercise Walks 30 min 2-3 times per week Religious Practices Christian Sleep Averages 6 hours of sleep per night Sexual History Pt recently divorced and is not sexually active currently, but wishes to be in the near future. Last sexually active 9 months ago with her now ex-husband. Laboratory Orders: b-HCG / urine pregnancy testing - Result: Negative Urinalysis - Result: Unremarkable / within normal limits STI testing (gonorrhea, chlamydia, Wet mount- yeast/BV, trichomoniasis, HIV, RPR) - Result: All tests were negative / unremarkable Physical Exam: Gen: Pt is well-developed, well-nourished, pleasant with normal affect Cardiac: RRR, S1/S2, no murmurs Pulm: CTAB, no crackling, wheezing, rales Abdomen: Soft, nontender, +BS X 4 Extremities: No edema, no palpable cords, negative Homan’s bilaterally Pelvic Exam: Multiparous cervix, anteverted, no adnexal masses or tenderness External genitalia: Normal; no lesions or masses Vagina: Pink, moist, well rugated; no blood or abnormal discharge present Cervix: Multiparous, no lesions, no discharge or bleeding present This patient went home after the most recent office visit awaiting the pending results of her diagnostic tests to determine next steps in her care, which is the reason for her visit today.
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