see attachment
Denise, a 19-year-old female presents to the clinic for an annual physical exam. She is
G0P0, and presents with irregular menses only occurring every 3-4months apart within
the past 2 years. She is sexually active and only using condoms occasionally. She is not
on any other birth control methods. She denies any significant medical or surgical health
history and denies any other current health problems. She has never had a Pap smear or
any pelvic exam tests before today. Her pregnancy test is negative and her vital signs are
all WNL.
SOAP NOTE
S – Subjective
CC: “I want birth control and my periods are irregular.”
HPI:
Denise is a 19-year-old G0P0 female presenting for her annual exam. She reports
irregular menses occurring every 3–4 months for the past 2 years. She is sexually active
and occasionally uses condoms. She denies any history of abnormal vaginal discharge,
pelvic pain, or previous STIs. Denies fatigue, weight gain/loss, or hirsutism.
Additional questions to ask:
• When was your last menstrual period (LMP)?
• Any recent changes in stress, weight, or exercise habits?
• Any family history of PCOS, thyroid disorders, or reproductive issues?
• Number of lifetime partners? Current partner status?
• History of STI testing?
• Desire for pregnancy in the next year?
Medical History: Denies chronic illnesses, surgeries, or hospitalizations.
Social History:
• Home: Lives with parents.
• Education: In college.
• Alcohol/Drugs: Denies drug use, occasional alcohol socially.
• Smoking: Denies.
• Sexuality: Heterosexual, sexually active.
• Contraception: Inconsistent condom use.
O – Objective
Vital Signs: WNL
General: Alert, cooperative
POCT:
• Urine pregnancy test (Negative – already obtained)
• Gonorrhea/Chlamydia NAAT (recommended)
• TSH if concern for endocrine cause of irregular menses
• Consider HbA1c or fasting glucose if PCOS suspected
Pap smear: Not indicated at this time. According to USPSTF and ACOG guidelines,
cervical cancer screening with Pap smear begins at age 21 regardless of sexual activity.
She may have the option now if she consents, but it is not mandatory until age 21
Pelvic exam: May perform if patient consents, especially for STI testing or symptoms
A – Assessment
Primary Diagnosis:
• Irregular menses, likely secondary to an-ovulation (ICD-10: N92.6 – Irregular
menstruation, unspecified)
Differential Diagnoses:
• Polycystic Ovary Syndrome (PCOS) – Consider due to menstrual irregularity and
adolescent age
• Hypothyroidism – Should rule out with TSH if symptomatic
P – Plan
Pharmacologic:
• Prescribe Combined Oral Contraceptive Pill (COCP): e.g., Ethinyl estradiol 30
mcg/norgestimate 0.25 mg PO daily, 28-day pack. 12-month supply, 0 refills
o Rationale: Effective birth control and cycle regulation
o Consider patient preference: patch, ring, or progestin-only if COCP contraindicated
Non-Pharmacologic:
• Educate on condom use for STI protection
• Offer HPV vaccine if not received
• Offer STI screening: GC/Chlamydia, HIV
Education:
• Discuss expected changes with COCP (lighter, more regular periods)
• Discuss adherence importance: same time daily
• Common side effects: nausea, breast tenderness, spotting
• Risk/benefit: COCP decreases ovarian/endometrial cancer risk but increases risk of
DVT in smokers or those with risk factors
• Reinforce safe sex practices and routine STI testing
• Encourage follow-up in 3 months for contraceptive tolerance and cycle regularity
Referrals:
• None needed at this time unless abnormal labs
Follow-up:
• Return in 3 months or sooner if side effects present themselves
• Annual physical exam and STI testing per guidelines
