SOAP Note 1
Age: 25 y.o.
Past Medical history: None
Past Surgical History: Tonsillectomy age 7
Family history: Mother Diabetes, Father Hyperlipidemia
Employment: works as a phlebotomist full time
S: Maria is an established patient who presents to office today for birth control. Pt is in a monogamous relationship with her current boyfriend of 4 months and is using condoms 100% of the time. Pt would like to start a more reliable form of birth control. Menarche 12 y.o menses: every 28 days and lasts for 5 days, patient denies cramps or irregular menses history. Patient is a non-smoker and does not use any substances. Last pap was 6 months ago negative for cytology. Gonorrhea and Chlamydia culture 6 months ago was neg/neg. HPV vaccine completed.
O: 5 feet 6 inches 140 pounds 98.4-80-16-122/76
General: Healthy appearing Hispanic woman in no apparent distress
Skin: No skin lesions identified
Head: Normocephalic, good hair distribution, no alopecia no nits
Eyes: Symmetrical with no erythema or discharge. Vision grossly normal
Ears: Symmetrical with gross hearing intact
Nose: midline, no septal defect, no discharge
Mouth: good dentition, moist mucous membranes
Cardiac: HR 80 normal sinuses rhythm, no S3 or S4, no arrhythmias noted
Lungs: Clear to auscultation bilaterally A & P, no use of accessory muscles
Abdomen: flat, soft, non-distended. Bowel sounds active in all 4 quadrants, tympanic throughout, no hepatosplenomegaly, no rebound or guarding.
A: Contraception Counseling
P: Diagnostics up to date
Education: During the 20-minute face-to-face visit, I discussed with patient the various forms of contraception including barrier, hormonal, non-hormonal, abstinence and natural family planning. Discussed efficacy, cost, risks and benefits of each method, using the Birth control option handout. Discussed timing to start method and how to use method to ensure efficacy. Patient decided to start oral contraceptives. Discussed Sunday start, daily dosing, missed pills, common side effect and major side effects, such as ACHES and when to call.
Continue Condom use for STD prevention
Pharm: Ortho-Tricyclen 28 day, 1 pill every day to start on Sunday after first day of menses. 3 refills
Follow- up: 3 months