Date & Time: 4/20/23 11:20 am

Full Name: J. L.

DOB: 1997

Location: Woodhull hospital

Source of information: self

Reliability: reliable

CHIEF COMPLAINT: discharge x 4 days

HISTORY OF PRESENT ILLNESS:

26 y/o G1P1001 female LMP: 11/06/2023 presents for annual exam c/o vaginal itching x 4 days. Reports she noticed odorless white clumpy discharge that has gotten progressively worse over past few days. Patient admits to multiple episodes of unprotected sex over the past month with multiple sexual partners both male and females. Denies fever, chills, dysuria, hematuria, urinary urgency/frequency, dyspareunia, abdominal pain, vaginal bleeding, nausea, vomiting.

LMP: 11/06/2023, q monthly, regular, 3-5 days

Patient counseled and declined contraceptives at this time.

Differential Diagnosis:

• Candidiasis: pt complains of vaginal itching and white clumpy discharge. 
• Chlamydia: patient is sexually active with multiple partners and states she does not always use protection. 
• Gonorrhea: see above
• Bacterial vaginosis: pt complains of discharge, however discharge is odorless, making this dx less likely.

MEDICAL HISTORY:

Medications:

• No current medication use.
• Denies OTC or herbal supplement use

Medical History:

• Chlamydia – July 2021, treated
• Patient denies medical problems

Immunization Hx:

• Gardasil – completed series 
• Declines influenza vaccine
• Declines COVID vaccine

Surgical History:

• Denies previous surgeries 

Allergies:

• No known drug allergies
• No known food allergies
• No known environmental allergies

Family History:

• Mother: alive & well, no significant PMHx
• Father: alive & well, hx DM
• Maternal and Paternal grandparents: deceased unknown reasons

Social History:

• Nonsmoker
• Admits to social alcohol use 1-2x per week
• Denies illicit drug use
• Occupation: mta worker
• Caffeine: Denies caffeine use.
• Marital history: Single
• Home situation: living in apartment with mother and son
• Diet: patient reports vegetarian diet
• Exercise: patient reports gym visits 3x per week

OB History:

• G1P1001
  • Pregnancy outcomes:
    • #1 spontaneous vaginal delivery full term no complications 5 years ago, no complications. 

GYN/Sexual history:

• Menarche: age 13
• Menstrual cycle: regular, lasts 3-5 days avg
• LMP: 04/06/23
• Pap performed today; previous pap 11/20 nml
• Sexually active multiple partners male and female.
• Contraception: Reports sporadic condom use. Declines oral or other contraceptive forms.
• History of + Chlamydia treated 2021

ROS:

• General: Denies recent weight loss, changes in appetite, weakness, fatigue, fever, chills.
• Skin, hair, nails: Denies discolorations, pigmentations, moles/rashes, changes in hair distribution or texture, pruritus.
• Head: Denies headaches, vertigo or head trauma.
• Eyes: Denies blurred vision, photophobia, or changes in vision.
• Ears: Denies pain, discharge, or changes in hearing.
• Nose/sinuses: Denies discharge, congestion, and epistaxis.
• Mouth/throat: Denies bleeding gums, sore throat, mouth ulcers, voice changes.
• Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.
• Breast:  Denies masses, nipple discharge or pain.
• Pulmonary system: Denies dyspnea, cough, wheezing, and dyspnea on exertion.
• Cardiovascular system: Denies history of HTN, chest pain, syncope, palpitations, hx of known heart murmur.
• Gastrointestinal system: Has regular bowel movements daily. Denies constipation, diarrhea, bloody stool, nausea, vomiting, and hemorrhoids.
• Genitourinary system: Denies dysuria, incontinence, urinary frequency.
• Menstrual/Obstetrical – See OB/GYN hx and HPI above.
• Nervous: Denies loss of strength, seizures, loss of consciousness.
• Musculoskeletal system: Denies muscle/joint pain, deformity or swelling, redness or arthritis.
• Peripheral vascular system: Denies intermittent claudication, peripheral edema.
• Hematological system: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.
• Endocrine system: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.
• Psychiatric: Denies depression, anxiety, hx of seeing mental health professional.

PHYSCIAL:

General: AAO x 3. Appears stated age.

 Vitals:

• BP: 118/77
• Pulse: 64, regular
• Temp: 98.6 oral
• Wt: 114 lb
• Ht: 62 in
• BMI: 20.8 kg/m²
• LMP: 11/06/2023

Skin/Hair/Nails: Skin nonicteric, no lesions noted, no tattoos. Hair average quantity and distribution. No clubbing of nails.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored, no use of accessory muscles noted.

Lungs: Clear to auscultation bilaterally, no adventitious sounds noted. Chest expansion and diaphragmatic excursion symmetrical.

Abdomen: Abdomen flat and symmetric, no striae noted. Bowel sounds normoactive in all four quadrants. Non-tender to palpation, no guarding or rebound noted. No CVA tenderness appreciated.

Breast:  No dimpling of skin, non-tender, no masses. Nipple without discharge or lesions. Axilla: no palpable axillary nodes

Female Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink with white clumpy discharge noted. Cervix pink and without lesions. No cervical motion tenderness. Uterus anterior, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained.

Rectal: Deferred. 

ASSESSMENT:

26 y/o G1P1001 here for annual c/o vaginal itching with white clumpy discharge x 3 days.

PLAN:

#Annual

• Perform pap smear and HPV test
• GC/Chlamydia testing
• Offer HIV testing as well as full STD panel
• Urine pregnancy test
• Call pt if results come back positive for GC/chlamydia and start antibiotics

#Candidiasis

• Diflucan 150 mg PO QD