History

 

Identifying Data:

Full Name: Mrs. G

Address: Not Disclosed

Age: 34

Date & time: 3/26/2021 3:00 PM

Location: Woodhull Women’s Health Clinic

Religion: Not disclosed

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Self

 

Chief Complaint: “Vaginal discharge and itch” x6 months

 

History of Present Illness:

34 year old F G5P3023 history of HPV/abnormal pap, anemia, copper IUD in place presents to women’s health clinic complaining of vaginal itch and white discharge x6 months. Reports itch and discharge occur 1 week before menses then resolve spontaneously. Tried OTC cream with no improvement, has since stopped using cream. Also reports heavy menses for past 2 years since copper IUD was placed. LMP 3/24/21, denies bleeding today. Patient states her PCP told her she is anemic and has been working up for other causes of anemia. As per patient, last pap was in 2018 and was abnormal. Pap followed by colposcopy reportedly told it was okay and did not require further follow up. Denies dyspareunia, dysmenorrhea, polymenorrhea, metrorrhagia, fever, chills, nightsweats, dizziness, headache, history of bleeding disorders, CP, palpitations, SOB.

 

 

Past Medical History:

Anemia – 2019

Childhood illnesses – denies any significant childhood history

Immunizations – Received flu vaccine

 

Past Surgical History:

Denies surgical history

Denies appendectomy, cholecystectomy, cataracts

 

Medications:

No prescription medications

No recent changes in medications

No vitamins, herbal teas or supplements

 

Allergies:

NKDA

No known environmental allergies

No known food allergies, no shellfish or seafood allergies

 

Family History:

Denies significant family history

Denies family history GYN cancers

 

Social History:

Mrs. G is a married female living in an apartment with husband and 3 children

Habits- Does not drink alcohol. No current or past tobacco smoking. Denies history of substance abuse or illicit substance use. Denies caffeine consumption

Travel-No recent international travel

Sleep-Sleeps 6 hours per night

Sexual history- 1 partner, husband. Last intercourse 3/15/2021. Denies history of HIV. Last pap in 2018, abnormal as per patient HPV

 

Review of Systems:

 

General-See HPI

 

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

 

Head – See HPI

 

Eyes – Denies vision changes, visual disturbances, fatigue, lacrimation, photophobia

 

Ears – Denies deafness, pain, discharge, tinnitus. No hearing aids.

 

Nose/sinuses – Denies discharge, obstruction or epistaxis.

 

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam 1 year ago, no dentures

 

Neck – Denies lumps, swelling, stiffness, decreased ROM

 

Pulmonary system – See HPI

 

Cardiovascular system –See HPI

 

Gastrointestinal system- Denies dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, changes in bowel habits, hemorrhoids, constipation, rectal bleed, blood in stool, flank pain

 

Genitourinary – Denies dysuria, frequency, hematuria, incontinence, nocturia

 

OB – See HPI

 

Nervous –Denies seizures, loss of consciousness, sensory disturbances, ataxia

 

Musculoskeletal– Denies muscle/joint pain, deformity, swelling

 

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

 

Hematological system –Denies easy bruising, lymph node enlargement, blood transfusions, or history of DVT/PE.

 

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

 

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.

 

Vital Signs

BP: Seated 110/77

HR: 66 BPM, regular

RR: 16 breaths/minute, unlabored

Temp: 98.6 degrees F orally

O2 Sat: 99% on room air

 

Physical Exam:

 

General: Comfortable female, well groomed, in no acute distress. Alert and oriented x3. Appears stated age.

 

Skin:   warm & moist, good turgor. Nonicteric, no lesions, scars, tattoos.

 

Hair:   average quantity and distribution

 

Nails:   no clubbing, capillary refill <2 seconds throughout.

 

Neck –Trachea midline.   No masses; lesions; scars; pulsations noted. no palpable adenopathy noted.

 

 

Chest – Symmetrical, no deformities, no evidence trauma. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1.   Non tender to palpation.

 

 

Lungs – Clear to auscultation and percussion bilaterally, no adventitious sounds.

 

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

 

Abdomen: Abdomen soft and nontender to palpation throughout. Tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly or CVA tenderness appreciated. Bowel sounds normoactive in all four quadrants

 

Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix multiparous, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear and culture obtained

 

 

Breast: Declined

 

Assessment:

34 year old F G5P3023 history of HPV/abnormal pap, anemia, copper IUD in place presents to women’s health clinic complaining of vaginal itch, white discharge x6 months, menorrhagia, and history of abnormal pap.

 

Plan:

1. Vaginal discharge & itch
   1. Culture obtained
   2. Presumptive candidiasis
   3. Rx Diflucan 500 mg PO once
2. History of abnormal pap
   1. Pap obtained
3. Menorrhagia
   1. Rx iron
   2. Pelvic and transvaginal US
   3. Educated about copper IUD and side effects including heavier menstruation, patient wishes to keep copper IUD in place for now.
   4. Being worked up by PCP for alternate causes of anemia