Taylor Best Case
CC
Taylor is an 18-year-old female here today to discuss her menstrual cycles.
HPI
The patient tells me her menstrual cycles are "not great". She says that she is noticing that they are very heavy. They are lasting about a week to a week and a half and she is having a lot of dysmenorrhea as well. In addition, they are not regular. She said this is they way they have been since she was 13. We have talked about this in the past and it one point, she was placed on birth control using Tri Sprintec in 2012. She took it for a little more than a year and then due to family circumstances was not able to refill her medications and she has been off it now for at least the last six months or so. She said initially, the periods when not as heavy and they were not as long, but the last couple of months they have been returning back to the way that they had been. She is interested in getting back on the birth control pill at this time. She is currently not sexually active, but has been previously sexually …show more content…
We did talk about options and I did elect to restart her on the Tri Sprintec one p.o. daily #1 with five refills. We talked about how to start the pill and what to be watching for. We reviewed the use and side effects of medication including the risks associated with its use and she will let me know if she is having any problems or concerns with it. She should schedule a physical, which she will do at her earliest convenience, and we will do a full exam at that time. She did leave a urine sample for screening of Chlamydia and gonorrhea today and she knows to call me if she has not heard from me in a couple of days with that result. I did talk about the importance of abstinence or 100% condom use. She will follow up then as above, sooner follow up as necessary. She does voice understanding of these recommendations. All questions
Taylor is an 18-year-old female here today to discuss her menstrual cycles.
HPI
The patient tells me her menstrual cycles are "not great". She says that she is noticing that they are very heavy. They are lasting about a week to a week and a half and she is having a lot of dysmenorrhea as well. In addition, they are not regular. She said this is they way they have been since she was 13. We have talked about this in the past and it one point, she was placed on birth control using Tri Sprintec in 2012. She took it for a little more than a year and then due to family circumstances was not able to refill her medications and she has been off it now for at least the last six months or so. She said initially, the periods when not as heavy and they were not as long, but the last couple of months they have been returning back to the way that they had been. She is interested in getting back on the birth control pill at this time. She is currently not sexually active, but has been previously sexually …show more content…
We did talk about options and I did elect to restart her on the Tri Sprintec one p.o. daily #1 with five refills. We talked about how to start the pill and what to be watching for. We reviewed the use and side effects of medication including the risks associated with its use and she will let me know if she is having any problems or concerns with it. She should schedule a physical, which she will do at her earliest convenience, and we will do a full exam at that time. She did leave a urine sample for screening of Chlamydia and gonorrhea today and she knows to call me if she has not heard from me in a couple of days with that result. I did talk about the importance of abstinence or 100% condom use. She will follow up then as above, sooner follow up as necessary. She does voice understanding of these recommendations. All questions