Claudia is a 36-year-old mother of two G2P2, she recently delivered her last child 9 months ago, and has been using condoms for birth control for the last 7 months. Today she is requesting a more reliable birth control, she is not sure of her current pregnancy plans, however, she does not wish to discuss sterilization. No religious contraindications for treatment. Previous methods include condoms, and oral contraceptive pills. She thought about an IUD but is concerned her husband may feel it during intimacy.
PMH: positive for mild hypertension with first pregnancy, seasonal allergies.
Surgeries: Left inguinal hernia and tonsillectomy.
Family history: Mother HTN and Father colon CA both deceased
Social History: Denies tobacco use, wine one to two glasses a week, denies recreational drugs, exercises twice a week.
Drug allergies-Sulfa causes a rash. Current medications-MVI with Fe, Calcium chews, prn Allegra for allergies. Height 67 inches, weight 157 pounds, BP 110/75, P 70, R 16. PAP collected today, breast exam WNL, urine pregnancy negative.
Physical exam is normal.
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