Assessment
Z30.013- Encounter for initial prescription of injectable contraception. This initial diagnosis is aimed towards switching her birth control medication to the Depo-Provera. Her primary care provider referred her to this OBGYN clinic for management of birth control. She previously had been taking an oral contraceptive pill and was taking it at random times each day. Her provider, according to the patient, had told her that she was to take it daily and did not specify that it should be taken at the same time every day. There were no recommendations towards any specific time the patient should be taking her oral contraceptive medication and just to take it every day. The patient liked the idea of not having to take a pill every day since she would sometimes forget her pill all together and researched other options online and came across the injectable birth control medication. …show more content…
This diagnosis is directed towards her already having a diagnosis of migraines. She denies having an aura or even knowing what an aura was. I thoroughly explained to the patient what an aura was and she denied having these. Migraines tend to be unilateral that worsen with activity and movement (Uphold & Graham, 2013). They range from moderate to severe intensity and the patient states that her headache pains range from an 8 to 10 on the pain scale (Uphold & Graham, 2013).
G43.C0- Periodic headache syndromes in child or adult, not intractable. I chose this as my differential diagnosis to migraines due to the fact that she is a high school senior and although denies any stress, it is likely that she consistently stares at a book or a computer screen most of the day. This could also lead to a tension migraine, which tends to occur during stress, fatigue or even lack of sleep (Uphold & Graham, 2013).
Plan Management
Z30.013- Encounter for initial prescription of injectable contraception. This initial diagnosis is aimed towards switching her birth control medication to the Depo-Provera. Her primary care provider referred her to this OBGYN clinic for management of birth control. She previously had been taking an oral contraceptive pill and was taking it at random times each day. Her provider, according to the patient, had told her that she was to take it daily and did not specify that it should be taken at the same time every day. There were no recommendations towards any specific time the patient should be taking her oral contraceptive medication and just to take it every day. The patient liked the idea of not having to take a pill every day since she would sometimes forget her pill all together and researched other options online and came across the injectable birth control medication. …show more content…
This diagnosis is directed towards her already having a diagnosis of migraines. She denies having an aura or even knowing what an aura was. I thoroughly explained to the patient what an aura was and she denied having these. Migraines tend to be unilateral that worsen with activity and movement (Uphold & Graham, 2013). They range from moderate to severe intensity and the patient states that her headache pains range from an 8 to 10 on the pain scale (Uphold & Graham, 2013).
G43.C0- Periodic headache syndromes in child or adult, not intractable. I chose this as my differential diagnosis to migraines due to the fact that she is a high school senior and although denies any stress, it is likely that she consistently stares at a book or a computer screen most of the day. This could also lead to a tension migraine, which tends to occur during stress, fatigue or even lack of sleep (Uphold & Graham, 2013).
Plan Management