Patient Information:
EG, 38, F,
S.
CC (chief complaint): 38-year-old female presents to the clinic to discuss contraceptive options.
She states she is not interested in having more children, but her new partner has never fathered a
child.
HPI:
Current Medications: Vitamin C
Allergies: No known drug allergies.
PMHx: Include exercise-induced asthma, varicose veins, and IBS. Surgical history remarkable
for tonsils as a child and bilateral vein stripping. Hospitalizations were only for childbirth.
Soc & Substance Hx: Negative for alcohol and recreational drugs; she reports smoking
cigarettes at a rate of one pack per day (PPD) since age 16, with short breaks when she was
pregnant. She does have smoke alarms in her home. Her living environment is stable without
issue. She is currently in a relationship with her male partner of two years. She is an accountant.
Patient reports not having a lot of time for hobbies but does take a yearly vacation with her
family. She has a good support system with her partner, her siblings, and her church.
Immunizations: Up to date on all childhood vaccines. Flu vaccine 9/7/2023. Did not take
COVID vaccines. Last Tetanus Shot 8/2022.
Fam Hx: Maternal grandmother is alive with Dementia. Her Maternal grandfather is alive with
COPD. Her paternal grandparents are both deceased due to a car accident. Her mother is alive
with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell).
Elaine has one older sister and one younger brother, neither with any reported medical problems.
Surgical Hx: Tonsillectomy as a child and bilateral vein stripping.
Mental Hx: Denies depression, anxiety, or suicidal ideations.
Violence Hx: Denies any concerns for her safety. She is a loving relationship with her partner of
two years.
Reproductive Hx: LMP: December 7, 2023. old G5 P5 LC 6. Nursing: no. No contraceptive
use. Intercourse oral and vaginal. Gender sexual preference: Patient is married to her husband,
male. No sexual concerns at this time. Pt requesting
Additional Patient Questions:
Have you and your partner used any form of contraception in the past, and if so, what
was your experience with it?
Are there any specific contraceptive methods that either you or your partner prefer or
have concerns about?
Have you and your partner discussed your long-term family planning goals?
Are you both on the same page regarding the desired number of children, if any, in the
future?
How do you and your partner communicate about family planning decisions?
Have you considered involving your partner in the discussion about contraception
preferences?
Are there any health or lifestyle factors for you or your partner that might influence the
choice of contraceptive method?
Do either of you have any medical conditions or take medications that could impact
contraceptive options?
Would you be interested in educational materials or counseling sessions to explore
contraceptive options more comprehensively?
Do you have any specific concerns or questions about the safety and efficacy of different
contraceptive methods?
These additional questions aim to gather more information about the couple's dynamics,
communication, and future family planning goals. It helps the healthcare provider offer
personalized and informed contraceptive counseling based on the specific needs and preferences
of the patient and her partner.
ROS:
GENERAL: Denies fever, chills, weight loss, or fatigue.
HEENT: Eyes: Denies blurred, vision or double vision. Denies visual loss. Ears, Nose, Throat:
Denies hearing loss, ringing in the ears, sneezing, congestion, runny nose, or sore throat.
SKIN: Reports no bruising, lesions, wound, or rashes.
CARDIOVASCULAR: Denies palpitations, chest pain or edema.
RESPIRATORY: Denies shortness of breath or coughing
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