History Blurbs

GYN Contraception Visit

# LARC Clinic Contraceptive Counseling

Patient attended LARC counselling today. She was educated on contraceptive options including Paraguard, Mirena, Nexplanon, oral contraceptives, and barrier protection. She was informed of the mechanism of action for each contraceptive option and efficacy, as well as the common side effects and risks of the procedure involved. She is understanding of the options available at our Branch Health Clinic and will pursue scheduling a procedure as desired. 

**Significant History**

Allergies: {}

Current Medications: {}


Vaginal deliveries: {}

C-sections: {}

Patient denies history of abnormal PAP.

Date of last PAP: {}

**Menstrual history**

Age of Menarche: {}

LMP: {}

Periods occur every {} days and last for {} days

Periods are associated with{ heavy bleeding;}{ cramping;}{ acne;}{ mood swings}

**Previous contraceptive methods**

Paraguard {|never||year – year - side effects?|}

Mirena {|never||year – year - side effects?|}

Nexplanon {|never||year – year - side effects?|}

Birth control pill {|never||year – year - side effects?|}

Depo shot {|never||year – year - side effects?|}

**Current method of contraception**: {}

**Potential Risk Factors**

Patient {denies} tobacco use.

Patient {denies} history of STD.

Patient {denies} personal or family history of stroke, blood clots, migraine headache with aura, breast cancer, ovarian cancer, or uterine cancer.

**Desired form of contraception**

After the group counseling, the patient decided she would like {|oral contraceptive pills||Nuvaring||Depo Shot||Paragard IUD||Mirena IUD||Nexplanon|} for contraception.

URO Pre-Vasectomy Visit

#### HPI

{ } year old patient here for vasectomy pre-procedure counseling.  Married { } years.  { } children, {ages & sexes}.  No future children desired. 

{No hx of STI}

{No testicular trauma}

{No hx of inguinal hernia}




#### Physical Exam

GU: { Normal penis and testes. }{ NO penile lesions. }{ NO urethral discharge. }

    Left: {NO scrotal mass, }{ NO scrotal tenderness, }{ NO epididymis tenderness, }{ NO hernia. } 

    Right: {NO scrotal mass, }{ NO scrotal tenderness, }{ NO epididymis tenderness, }{ NO hernia.}


#### Assessment & Plan

## Vasectomy Counseling

Patient desires to continue with procedure. 

Pre-procedure counseling completed.

{- Patient given information regarding scheduling for vasectomy}

{- Pre-procedure prescription for diazepam PO 5mg x 2 doses given}

- {}

#### Follow-Up: On day of procedure

*Patient seen in the clinic.  10 point ROS completed, all neg except as indicated.  The following exam was performed: Vitals reviewed. General appearance assessed. Neurologic gross assessed. Cardiovascular perfusion assessed. Respiratory status and effort assessed. Genitalia examined. Previous EMR records reviewed. Labs reviewed. Radiology results reviewed. Medication list was verbally reconciled with the patient, updated. Depression screening performed with PHQ-2 on intake; Safety assessment performed with safety question on intake; All screeners negative unless discussed.*

Breast Health History

***-Breast health history-***  

Age of Menarche: {}

Age at first pregnancy/childbirth: {}


OCP use for {} years {consistently}

{No} personal history of breast cancer

{No} family history of breast cancer

{No} history of breast biopsies

{No} history of breast radiation

Cardiac History


{ }

{No history of MI }

{No history of stroke }

{No history of cardiac catheterization }

Cardiac imaging/study history:

{ }

░░░ Past Medical/Surgical/Social/History ░░░

{}Reviewed past records in AHLTA.


{NO 1st degree relatives with early cardiac death}

{NO 1st degree relatives with early stroke}

{NO 1st degree relatives with DM}