CASE EXAMPLE: The Evaluation of a Patient Seeking Contraceptive Services Using the Problem Oriented Record System Before the patient is introduced to the doctor or nurse clinician in the examining room she has 1) been counseled by clinic personel about the different methods of birth control with special attention paid to the particular method(s) the patient is seeking 2) filled out the patient questionaire (form 080) 3) had preliminary lab workup (e.g. blood, urine, pregnancy test if indicated). The patient then enters the examination room and is introduced to the physician or nurse clinician. It is noted that the patient would like to use oral contraceptives, has used only those methods of birth control that do not require a physician, and has had no previous problems with birth control in the past. The following questions were answered yes by the patient on the Patient Questionnaire and are discussed with the patient as they may represent a contraindication to the method of birth control that she has chosen. Question #4 "Do you ever want more (or any) children?" The patient wishes to have two more children but does not desire to get pregnant for at least four more years. A horizontal line is drawn through all five columns under the different contraceptive methods on the Entry Data Base. The presence of white boxes under the injection column and sterilization column indicate that these methods are contraindicated for this patient. Question #8 "Have you ever had high blood pressure?" The patient is six weeks postpartum. She had high blood pressure during her recent pregnancy (170/110). Her blood pressure is 150/100 at the time of examination. A similar line is drawn through the boxes for item 8. Hypertension is a contraindication to oral contraceptives only. Question #9 "Does anyone in your family have high blood pressure?" The patient's parents, it is learned, are both hypertensive and both are currently on medication. Again a line is drawn and again orals are contraindicated. Question #10 "Have you ever had pains or clots in your legs?" During her last pregnancy the patient was diagnosed by her obstetrician as having phlebitis during the second trimester. A line is drawn through the method boxes. Oral contraceptives with estrogen are contraindicated. PHYSICAL EXAMINATION The only abnormal finding during the physical examination was a high blood pressure, 150/100. X's are placed in the "X if norm❞ box for all the items except #34 Blood Pressure. Here a line is drawn through the boxes of item #34 under the columns of contraceptive methods. LABORATORY Laboratory results are all normal and Xs are placed in the boxes under "X if norm." ASSESSMENT Reviewing the findings from The Medical History, Physical Examination, and Laboratory the physician or nurse clinician must evaluate the contraindications found for each method. Oral contraceptives are contraindicated by items 8,9,10 and 34. The IUD has no contraindications. Injection (Depo Provera) is contraindicated by item 4 (given the guidelines used in this clinic). Other methods, such as foam and condoms, diaphragm and jelly/cream, are not contraindicated. PLAN The patient is told that it is not medically sound for her to use the pill (her first choice of contraception) because of the possibility of potentiating her hypertension and the increased risk of phlebitis. The physician or nurse clinician then explains what alternative methods are available for the patient to use. The patient decides that an IUD would be the best method of contraception for her. The patient chooses a Lippes loop because her sister-in-law has one and has had much success with it. (When more than one type of IUD may be used by a patient it is often advisable to give her a choice or ask her if anyone she knows has a device that they are pleased with. This may increase patient acceptance and motivation.) A Lippes loop "D" is inserted and foam is also supplied to the patient. She should be told that use of another method of birth control (such as foam or condoms) during midcycle (days 10 to 18 of a 28 day cycle) will increase the effectiveness of the method. The patient is referred to the walk-in hypertension clinic for evaluation and treatment of the elevated blood pressure. XI. REFERENCES 1. Dingle, J.H., Badger, G.F., Jordan, W.S. “Illness in the Home: Study of 25,000 Illnesses In A Group of Cleveland Families." Press of Western Reserve University. 1964. Cleveland, Ohio. 2. Wray, J.D. and Aguirre, A. “Protein-Calorie Malnutrition in Candelaria, Colombia. I. Prevalence; Social and Demographic Factors." Journal of Tropical Pediatrics. 15:76-98, 1969. 3. Meyer, R.J., Roelofs, H.S., Bluestone, J., and Redmond, S. "Accidental Injury To The Preschool Child." Journal of Pediatrics. 63:95, 1963. 4. Gordon, J.E. "Social Implications of Health and Disease." Archives of Environmental Health. 18:216-234, 1969. 5. Wyon, J.B. and Gordon, J.E. "A Long-Term Prospective-Type Field Study of Population Dynamics in the Punjab, India." Research In Family Planning, |