Reason for Appointment/Chief Complaint:

"Discuss birth control options"

HPI:
19-year-old female presents with her significant other to discuss birth control options. States
currently on Mirena IUD for contraception and would like to go back on oral pills. She has
irregular spotting (at least 3 episodes of spotting per month) since Mirena was placed
12/19/2018. Previously taken the pill (Microgestin 1/20) for contraception and did well with it.
Takes daily vitamin consistently and believes she will be able to consistently take the oral
contraception. Has also used Depo-Provera in the past but does not desire to resume it due to
weight gain. Denies history of blood clots or blood clotting disorder.

Has had 3 positive chlamydia tests since 12/2018 with the most recent infection being diagnosed
earlier in June 2019. Reports following first two positive chlamydia tests, her and her previous
partner took their medication and abstained as recommended, but following most recent positive
test she did not take her medication as she misplaced it and desires for the medication to be re-
prescribed. She has been with her current partner for 1 month. Her partner has not received
treatment for any STIs in the past month. Besides frequent spotting, she denies any other
symptoms including fever, abdominal pain, change/increase/odorous vaginal discharge,
dyspareunia.

Current Medications:
1. Levonorgestrel 52 mg (Mirena) 20 mcg/24 hrs IUD—due to be removed 12/19/2023
2. Minocycline HCl 100 mg capsule orally BID
3. Women's Daily Vitamin

Allergies:
1. Latex—(Reaction: Rash)

Past Medical History:

1. Depression
2. Anxiety
3. Acne vulgaris

Surgical History:
1. Right breast mass excisional biopsy—4/28/2017
2. Tonsillectomy—3/12/2019
3. D&C—Date not available

Family History:
1. Mother: Alive, healthy
2. Father: Deceased due to MI at age 49, history of seizures
3. Brother: Alive, healthy
4. Sister: Alive, healthy
Social History:
1. Tobacco use: No
2. Alcohol use: None
3. Caffeine intake: Regular soda about 2-3 cans/day
4. Exercise: Daily, 30-60 minutes walking or running 5 times per week
5. Occupation: Student
6. Marital status: Single

Gynecological History:
1. Periods: Irregular cycle with Mirena IUD occurs about 3 times/month; LMP 5/26/2019
2. Sexual activity: Currently sexually active
3. Date/results of last pap smear: None
4. Last mammogram: None
5. Sexually Transmitted Diseases (STDs): Trichomoniasis (9/2017), Chlamydia--12/2018,
3/2019, 6/2019
6. Birth control: Mirena IUD inserted on 12/19/2018, remove on or before 12/19/2023
7. Age of Menarche: 12

Obstetric History:
1. Total pregnancies: 1
2. Total living children: 0
3. Miscarriage(s): 1
4. Pregnancy #1: Spontaneous abortion at 8 weeks with subsequent D&C

Review of Systems: (Highlight positive findings)

General: Fatigue, fever, chills
Skin: Itching, rashes, new or changing lesions
Respiratory: Denies shortness of breath.
Cardiac: Denies chest pain, palpitations, and edema.
Genitourinary: Dysuria, urgency, frequency, frequent UTIs
Gynecological: Changes in sexual function, heavy bleeding during menses, irregular bleeding,
painful intercourse, vaginal discharge/bleeding, itching, painful menses. Reports irregular light
menstrual spotting 3 times per month.
Psychiatric/Behavior: Anxiety, depression, new stressors

Objective Findings

Vital Signs:

Temp: 98.5 F Height: 64 in

HR: 78 beats/min Weight: 156.4 lbs
RR: 16 BMI: 26.84
BP: 126/72 mm Hg
Physical Exam:
General: Well developed, well nourished, no acute distress
Neurological: A&Ox3, clear and appropriate speech, maintains good eye contact
Skin: Pink, warm, dry and intact; no rashes, bruising, or suspicious lesions
Musculoskeletal: Gait intact, normal coordination
Cardiac: Regular rate and rhythm without murmur.
Respiratory: Respirations easy and even. Anterior and posterior breath sounds clear bilaterally.
Abdomen: Flat without pulsations. Bowel sound active. Soft and nontender throughout four
quadrants. No guarding. No masses.
Pelvic: External genitalia pink, moist, & without lesions; urethral meatus pink, moist, & intact;
Bartholin’s and Skene’s glands non-enlarged; vaginal vault non-erythematous moist, rugated
with no abnormal discharge, bleeding or lesions; cervix pink, round, tender to palpation, no
discharge, lesions, or bleeding; IUD strings noted exiting the cervical os; no cystocele, rectocele
or inguinal lymphadenopathy

Assessment:
1. General contraceptive counseling (Z30.432)
2. Removal of intrauterine contraceptive device (Z30.432)
3. Chlamydia infection (A74.9)
Differential Diagnosis: Gonorrhea, Pelvic Inflammatory Disease

Treatment Plan:
1. Remove Mirena IUD
a. Initially counseled patient that vaginal spotting may be related to frequent and
untreated chlamydia infections. Recommended treatment of chlamydia, retesting,
and continuing IUD while monitoring vaginal spotting. If vaginal spotting persists
despite chlamydia treatment, then can be removed and OCP started. Provided
reassurance that spotting (in the absence of chlamydia or other etilogy) does not a
medical problem and that contraceptive is still effective. Despite this discussion,
patient adamantly wants IUD removed today and to resume OCPs. Removed
without difficulty, device intact, procedure well tolerated.
2. Counsel on and initiate OCP for continued contraception:
a. Start Microgestin 1/20 tablet orally today, once daily for 21 days
b. Take at the same time each day to increase effectiveness and reduce adverse
effects of irregular administration including spotting
c. Discussed benefits such as less premenstrual symptoms, lighter more regular
monthly cycles, high efficacy if taken correctly
d. Explained risk for side effects such as breakthrough bleeding, nausea, breast
tenderness, headaches, and blood clots. Stressed the importance to avoiding
smoking, especially while taking OCPs due to the increased risk of DVTs.
e. Discussed how to start OCP and how to skip periods if desired
3. Start treatment for chlamydia
a. Start Azithromycin (Zithromax) 500 mg, 2 tablets orally taken once
b. Partner was offered partner treatment though he has never had STD screening so
he was instructed to go the health department or PCP to receive testing prior to
treatment for chlamydia
 c. Abstain from intercourse for 7 days while receiving treatment and 7 days after
partner is treated
d. Discussed risks of repeated chlamydia infections- PID, infertility, ectopic
pregnancies
4. Follow up in 3 months to retest for chlamydia and check up on OCP

Women's Health Clinic

1 University Ave.
Normal, IL, 61761

Tel:

Name: ABC DOB: 1/1/2000

Address: Date: 5/24/2021

Rx:

Azithromycin (Zithromax) 500 mg tablets

Instructions: Take 2 (Two) tablets once

Quantity: 2 tablets (Two)
Refills: 0 (Zero)

Signature: , FNP Student

NPI:

Women's Health Clinic

1 University Ave.
Normal, IL, 61761

Tel:

Name: ABC DOB: 1/1/2000

Reflection/Rationale

Chlamydia is the most frequently reported sexually transmitted infection (STI) in the
United States (Centers for Disease Control and Prevention [CDC], 2015). Often asymptomatic,
an untreated chlamydial infection can lead to serious complications such as pelvic inflammatory
disease, ectopic pregnancy, and infertility (CDC, 2015). The CDC (2015) recommends
azithromycin one gram orally in a single dose as the preferred treatment. An alternative
treatment is doxycycline 100 mg orally twice a day for seven days (CDC, 2015). The simplest
regimen was selected to promote treatment compliance.
With any form of contraception, it is important to consider the risks and benefits on an
individualized basis. My preceptor had some concerns about the patient’s ability to consistently
take a pill each day, but she also explained to me how ultimately it might be safer than an IUD,
given her history of repeated STI infections. An IUD can be used in a woman with a history of
STIs, but an ongoing pelvic infection is a contraindication to use (Milton, 2018). My preceptor
explained a woman with an IUD who acquires an STI and receives treatment could continue to
use an IUD for contraception. In this particular case, she believed using and replacing an IUD on
a long-term basis could be problematic if the patient continued to have frequent STIs. I found her
insight helpful and formative. This was an interesting case that helped me learn how to think
critically about recommending contraception to individuals.

References

Centers for Disease Control and Prevention. (2015). Chlamydia infections: Chlamydial

infections in adolescents and adults. Retrieved from

https://www.cdc.gov/std/tg/2015/chlamydia.htm

Milton, S. H. (2018). Intrauterine device insertion. Retrieved from

https://emedicine.medscape.com/article/1998022-overview