DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient is a (XX)-year-old nulliparous woman with LMP of MM/DD/YYYY, who came in for insertion of a ParaGard intrauterine device. We saw the patient at the end of January for an annual exam. Her Pap smear is still pending and her Gen-Probe was negative. The patient had been on birth control pills, but she gave a history of migraine headaches with visual symptoms, and we thought it best that she consider alternative contraception. The patient is interested in having a ParaGard intrauterine device.
The patient reviewed the consent form and we answered all her questions. The risks of the procedure were discussed including, but not limited to, bleeding, infection, and uterine perforation. The patient is aware that the highest risk of infection is in the first three months and that the intrauterine device is effective for 10 years but could be removed at any time.
OBJECTIVE: The patient is a healthy-appearing (XX)-year-old. Height 5 feet 7 inches, weight 168 pounds, blood pressure 120/70, pain score 2 for her headache.
PROCEDURE DETAILS: The patient was placed in the lithotomy position. A bimanual examination was done. The uterus was anteverted, mobile, and normal size. A speculum was placed in the vagina and the cervix swabbed with Betadine. Under sterile technique, the anterior lip of the cervix was grasped with a single-toothed tenaculum. The cervical os easily dilated to #10 Pratt dilator. The uterus sounded 3 inches. The ParaGard intrauterine device was inserted without difficulty and the strings were trimmed. The tenaculum was removed from the cervix and the speculum removed from the vagina. The patient tolerated the procedure well.
ASSESSMENT: Successful insertion of ParaGard intrauterine device.
PLAN: The patient was advised to check for the IUD string after every menses or at least after a heavy menses. If she is having no problem with the intrauterine device, she will be due for a visit next January.