C.C. Vaginal discharge Medications: Minestrin 28-day pack HPI

C.C. Vaginal discharge

Medications: Minestrin 28-day pack

HPI: 17 y.o. F presented to clinic by herself reporting “almost fish-like smelling discharge from my vagina

that started about a week ago.” She usually notices it after intercourse. She describes the discharge as

thick, tan, foul-smelling, slimy discharge. She also complains that she would sometimes have pain and

burning on urination. She tried to use Monistat gel with no relief with her symptoms. She reports

having only 1 sexual partner, boyfriend. They do not use condoms since she is on birth-control. Denies

abd pain, fever or chills. This has never happened before.

PMH: Diagnosed with asthma during early childhood, resolved, currently not taking any medications for it.

Immunizations: Up to date with childhood immunizations

. Influenza vaccine (October 2019).

ALLERGIES: NKDA

Family History: Father with GERD and hypertension. Mother with no significant past medical history.

Has an older brother and younger sister with no significant past medical history. No family history of

cancer.

Social History: Patient is a senior in high school. She lives with her family. Has a boyfriend and in a

monogamous relationship. Does not use condom, uses oral contraception. Admits to smoking cigarette

but does not use recreational drugs or alcohol.

HEALTH CARE MAINTENANCE: No hx of Pap Smear

Denies performing regular self-breast exam

Menarche: 13 y.o. Last menstrual period two weeks ago, regular periods

.

REVIEW OF SYSTEMS:

GENERAL/CONSTITUTIONAL: Patient denies any mood changes, change in appetite, weight loss/ gain,

fatigue, or fever.

SKIN: Denies any skin rashes, lesions, ulcerations, or abnormalities.

HEENT: Denies headaches, change in hearing, ear pain or ringing in the ears. Denies nasal congestion,

bleeding, drainage or change in sense of smell. Denies sore throat, dysphagia.

BREAST: Denies breast tenderness, mass, or lesion. Denies nipple abnormality or discharge.

CARDIOVASCULAR: No prior history of any cardiac problem. Denies chest pain, irregular pulse or the

feeling of the heart racing or missing beats.

PULMONARY: History of asthma, resolved. Denies SOB or pain with inspiration/ expiration.

GENITOURINARY: Denies vaginal itching. Denies history of pregnancy or STD. Complains of foul-smelling

vaginal discharge and pain with urination for 1 week.

GASTROINTESTINAL: Denies nausea, vomiting, hematemesis, abdominal pain, change in bowel habits, or

heartburn.

MUSCULOSKELETAL: Denies muscle pain, arm or leg weakness, joint swelling or arthritis.

PSYCHIATRIC: Mild depression.

NEUROLOGICAL: No Denies syncope, seizures, disorientation, anxiety, inability to concentrate, or

difficulty with balance.

Vital Signs: T 98.1 BP 121/82 HR 64 RR 12

Height 5’9″ Weight 124 lbs. BMP 18.31

PHYSICAL EXAM:

APPEARANCE: Pt is a pleasant 17 y.o. female who is awake and oriented. Well-groomed and dressed

appropriately.

SKIN: Skin warm, dry, and intact. No lesions or rash, petechiae, or ecchymoses noted.

HEENT: Head- Normocephalic, hair of coarse texture, no thinning or balding noted. Scalp without lesions

or flaking skin. Eyes- Sclera clear, conjunctiva pink. Visual fields are intact. Ears- without pain or

tenderness. Nose- Symmetric, no discharge noted. Throat- Oral mucosa pink, detention intact with no

notable missing teeth or gum irritation. No exudate.

NECK: Trachea at midline. No lymphadenopathy or thyromegaly.

BREAST: Symmetric, non-tender, without mass. No swelling, ulceration, or discharge noted.

CV: PMI at 5th intercostal space. S1 and S2 present. No murmur, thrills, or lifts. Regular rate and rhythm.

Extremities warm, dry, and well perfused.

PULM: A/P diameter WNL. Normal chest excursion. Breath sounds are clear to auscultation. No use of

accessory muscles or increased respiratory effort noted.

GI: Soft, Non-tender, non-distended with active bowel sounds.

GU/ PELVIC: Urethral meatus normal without discharge or irritation. External genitalia: no lesions noted,

vaginal walls pink, pubic hair, scant, shaven. Vagina: Mucosa moist and slightly reddened. Small amount

of thick, tan, odorous discharge noted. Cervix: pink, w/o lesion or mass. Bimanual exam: lower

pelvic tenderness, no palpable uterine or ovarian enlargement. Anus: No hemorrhoids or fissure noted.

MUSCULOSKELETAL: Extremities without clubbing, cyanosis, or edema. No scoliosis or kyphosis. ROM

WNL.

NEURO: Alert and oriented x3. Gait normal.

• The first part of the discussion board is to identify all pertinent positive and negative information.
• What other questions may you want to ask the patient?
• How will you address these findings?
• Now make a plan utilizing clinical practice guidelines for the priority diagnosis.