The 15-Year-Old Patient Evaluation & Management Plan

The patient presenting is a 15-year-old female accompanied by her mother for a gynecological examination and to discuss birth control options. The patient has become sexually active and the mother brought her in to discuss birth control options. The patient has had all her immunization, including the Gardasil shot, and she denies any sort of significant health history.

Being that this is the young girl’s first gynecological examination can be a very scary situation. It is very important to begin this examination process by explaining to the young girl the entire process, giving her an opportunity to ask questions, and make her as comfortable as possible. It is important to understand that the patient’s first gynecological examination gives an opportunity to evaluate the young woman’s reproductive health status and provides a time to provide essential guidance and education. This examination is an important component of care for many young women, as adolescents and young adults are at an increased risk for sexually transmitted infections, unplanned pregnancy, and other gynecologic complaints or concerns. This examination can cause anxiety and could possibly impact the young woman’s opinion in a negative way of future engagement in healthcare. Understanding how young women perceive the first pelvic examination is important to enable providers to optimally educate and prepare adolescents and young adults for this important and very intimidating examination. Making the young woman feel comfortable and helping to gain her trust is an important aspect to beginning a healthy relationship, and to have open and honest communication during your interactions. During the examination, the healthcare provider will discuss with this patient about the importance of contraception and sexually transmitted infections. It’s important to arm young women with the knowledge they need to protect themselves from infections and unplanned pregnancy (Ferguson & Chor, 2019).

It is important to know that during the health history, this is a time to establish a relationship with the patient, while learning important information about their health. This is a time to establish open and honest communication with the patient. The setting should be a comfortable and private location where the patient doesn’t feel rushed. It is also important to have a time with the patient to speak privately, to make her feel more comfortable, and possibly speak more freely without her mother in the room. The comprehensive history is one of the single most important aspects of a well-women visit. This health history includes report of symptoms, medications, allergies, medical and surgical history, questions about sexual and mental health, and information about menstrual cycle. This patient is also at the age where a discussion can be had about positive body image, intimate partner violence, and safe sexual practices (The American College of Obstetrics and Gynecologist, 2020).

According to the Centers for Disease Control and Prevention, the most common contraceptive methods that are currently used in the United States are female sterilization, the pill, the male condom, and long acting reversible contraception. Female sterilization increased with increasing age. Use of the pill decrease with increasing age (Centers for Disease Control and Prevention, 2020).There are many different birth control options and they all work differently on other, and some work better than others. The kinds of birth control that work the best to prevent pregnancy are the implant and IUDs. They are the easiest to use and the most fool proof. Some other methods that are good at preventing pregnancy, if used correctly is the pill, the patch and the shot. It’s super important to make sure you use your birth control the right way. This means you can’t forget to take your pill, change your ring, or get your shot on time, or you’ll be at risk for pregnancy. So the best method of birth control for you is the one you’ll always use correctly (Planned Parenthood Federation of America, 2021).

It is important to educate the patient that, for most women, birth control pills, vaginal rings, and contraceptive skin patches are very unlikely to affect their weight. Clinical studies in the area of birth control and weight gain are somewhat contradictory. Some women said that they gained weight, while others reported losing weight. This is why both weight gain and weight loss are listed as possible side effects on the product information of hormonal contraceptives. It is important for the young woman to know that hormonal contraceptives could contribute to weight gain if they led to fluid retention and increased body fat. Also, combined contraceptives are sometimes believed to increase appetite. But it’s not that easy to say whether that’s true because women who don’t use hormonal contraceptives also gain weight as they age. Many research studies have been conducted and the results found that it is very unlikely that hormonal contraceptives cause major weight gain. If there were a strong effect, it would have been noticed in the studies. But this doesn’t rule out the possibility that individual women could in fact gain weight (Institute for Quality and Efficiency in Health Care, 2018).

The patient has a right to weigh her birth control options, but she also needs to make sure that she is using condoms appropriately in the meantime to prevent pregnancy and STDs. It is important to educate her that using a condom correctly every time you have sex is the only way to reduce your risk of both pregnancy and STIs. Educating her on the correct way to use a condom to prevent any unwanted pregnancy or STDs is important. I would provide her with educational material, instructions and facts. I would also explain to her that abstinence is the only way to fully prevent pregnancy and STDs (Planned Parenthood Federation of America, 2021).


Centers for Disease Control and Prevention. (2020). National Center for Health Statistics. Centers for Disease Control and Prevention.

Ferguson, A., & Chor, J. (2019). Factors influencing young women’s preparedness for their first pelvic examination. Obstetrics and Gynecology Journal, 132(2).

Institute for Quality and Efficiency in Health Care. (2018). Contraception: Do hormonal contraceptives cause weight gain? U.S. National Library of Medicine.

Planned Parenthood Federation of America. (2021). What’s the best kind of brith control? Planned Parenthood Federation of America.

The American College of Obstetrics and Gynecologist. (2020). Well-Woman visit. The American College of Obstetrics and Gynecologist.

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