The patient is a 32-year-old female who presents to the clinic requesting a prescription for birth control.
May 5, 2024
The patient is a 32-year-old female who presents to the clinic requesting a prescription for birth control. She has been dating the same individual for 4 months and has inconsistently used a condom with intercourse. She describes herself as “healthy.” She admits to drinking “socially” an average of 4 glasses of wine each week. Her last menstrual period was one week prior to the visit. Her vital signs are as follows: BP 140/86, HR 98, R 16, T 98.2F, weight 170 pounds, height 5’6″. Current medications include montelukast 10 mg, fluticasone nasal spray, Vyvanse 20 mg and levothyroxine 112 mcg. She is requesting a prescription for an oral contraceptive (OC).
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