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Case 5.5 Birth Control Decision‐Making

By Jessica Chan, MSN, APRN, PPCNP‐BC

SUBJECTIVE

Lauren is a 17‐year‐old female who presents alone to the primary care office to discuss birth control options. She has been in a relationship with her boyfriend for 6 months and is currently sexually active with only him. She has a history of 1 partner prior to her current boyfriend. She reports using condoms always and never having unprotected intercourse. She has not discussed this with her mother yet, but does think she could be open about it. She has not had testing in the past for sexually transmitted infections (STIs), but would be interested and denies symptoms such as abnormal vaginal discharge, dysuria, pelvic pain, or any new rashes or lesions. She is due for her menses in 3 days. She generally has cramps the day before and the first day of her menses, and takes ibuprofen with good effect.

Past medical history: Lauren has a history of eczema and seasonal allergies.

Family history: Lauren’s biological mother has a history of dysmenorrhea.

Social history: Lauren lives at home with her mother, father, and younger brother. She is in the 12th grade and plays tennis for fun. She reports having many good friends and denies substance use.

Medications: Lauren’s medications include cetirizine (Zyrtec) 10 mg daily during allergy season and occasional triamcinolone cream for her eczema.

Allergies: NKDA.

OBJECTIVE

General: Well appearing, no acute distress

Vital signs: Weight: 145 lbs; height: 62 inches; BMI: 26.5; HR: 72; B/P: 116/74.

Cardiovascular: Regular rate and rhythm. S1/S2 normal.

Respiratory: Lungs clear to auscultation bilaterally.

Breast: Tanner V breast development noted. Not palpated at time of visit; at last annual physical exam had normal breast exam with no masses.

Gastrointestinal: Bowel sounds normoactive in all four quadrants. Soft, nontender, nondistended, with no hepatosplenomegaly.

Genitourinary: External exam with Tanner V pubic hair development noted and no lesions present.

CRITICAL THINKING

1 Given the information provided, what other questions would you ask?

2 What diagnostic or screening tests would you consider running on this patient?___Urine pregnancy test___Beta pregnancy test (serum hCG level)___Urine gonorrhea and chlamydia (GC/CT)___Serum HIV immunoassay and RT‐PCR (viral load)___Serum RPR (reactive plasma reagin) or VDRL (Venereal Disease Research laboratory) testing for syphilis___Pelvic exam with wet mount___Pap smear___Complete blood count (CBC)___Lipid panel (baseline cholesterol screening)

3 What are the concerns at this point?

4 What is the diagnosis at this point?

5 What types of contraceptives should be considered for Lauren?

6 How would each contraceptive option be initiated?

7 What are some common contraindications to contraceptives?

8 How should Lauren be counseled about side effects?

9 What are the plans for referral and follow‐up care?

10 What other education should Lauren be provided with related to reproductive health?

11 If the patient chooses not to discuss her choice to seek out birth control options with her mother, how would you proceed?

12 Are there any standardized guidelines that should be used to treat this case? If so, what are they?