S: L.L.

is a 27-year-old single, Caucasian female who comes to the

clinic today seeking a form of birth control and her annual physical
exam. She also has complaints of vaginal itching and discharge that
began 1 week ago.
Chief Complaint: I have had an increase in vaginal discharge, odor,
and itching over the last week, I also would like to start a form of birth
control, I have tried pills in the past, but I think I would like the NuvaRing better.
History of Present Illness: L.L. states that she has noticed an
increase in mucous colored discharge, a fishy odor, and itching over
the last week. The symptoms started after sexual intercourse with a
friend 10 days ago. The severity of the symptoms is mild, but
increases to severe if she attempts to have intercourse. Intercourse is
unbearable. Urinating is not painful, I just notice the smell. The
itching is constant. I do sometimes notice a mild lower abdominal
pain, that is worse if I press on it. She has not attempted to treat the
symptoms, but she has refrained from intercourse for the last two
days. No complaints of any associated fevers, chills, nausea, vomiting,
or diarrhea.
ALLERGIES:
Sulfa
Ceclor
Amoxicillin
Biaxin
Medications:
Multi-Vitamin with Iron
Immunizations:
Up to date on all childhood immunizations, however has not
received a vaccine since the age of 18.
Did not receive the HPV vaccine (not indicated for women after
the age of 26)
Does not believe in the Flu vaccine, therefore has never received
it.
Previous Screening Results:
Patient has recently moved to the area, therefore this is her first
pap smear collected at this facility.
States My pap smears have always been normal in the past.

Major Adult Illnesses:

Migraines- None currently and not on any medications
Depression- no medications
Trichomoniasis infection at the age of 17 and 19.
Five spontaneous abortions
Surgeries:
Incision and drainage of cysts on tailbone and cheek.
Family History:
Maternal Grandmother- Breast Cancer (deceased in her 60s)
Maternal grandfather-Stomach cancer (deceased in his 50s)
Maternal cousin- Breast cancer age of 35 (in remission)
Maternal Cousin- Breast cancer age of 40 (deceased at 42)
Mother- depression, and bipolar disorder, healthy otherwise (age
60)
Father- schizophrenia (unaware of fathers current condition)
Social History
Recently moved to the area from Virginia.
Works as a bar tender.
Drinks alcohol, including liquor, daily
Smokes cigarettes socially while at work.
Denies drug use
Lives alone in a 1-bedroom apartment.
Gluten- free diet
Sexual History
Partners: only male partners, sexual contact with 5 men in the
past month. I stopped counting sexual partners at 30.
Prevention of Pregnancy: Currently using the pull out
method to prevent pregnancy
Protection from STIs: occasionally uses condoms, but not
recently.
Practices: Last sexual encounter was vaginally.
Past History of STIs: Trichomoniasis infection at the age of 17
and 19.
Resources:
No health insurance, recently lost coverage.

Review of Systems:

Constitutional Symptoms: Reports overall good health, with no

complaints of recent weigh loss, gain, fever, or fatigue.
Eyes: Denies recent changes in vision, eye pain, or photophobia. Does
not wear any corrective lenses.
ENMT: Denies any ear pain, vertigo, tinnitus, hearing loss, runny nose,
epistaxis, sinus problems, or sore throat
Cardiovascular: Denies chest pain, shortness of breath, palpitations,
orthopnea, or syncope
Respiratory: Denies shortness of breath, cough, or wheezing
Gastrointestinal: Gluten free diet that has reportedly stopped
migraines from occurring and improved GI health. Daily Womens
vitamin with iron. No reports of heartburn, epigatric pain, nausea,
vomiting, or changes in bowel pattern. Reports mild lower
abdominal pain that is aggravated by palpation.
Genitourinary: Reports unprotected sex 3 days ago. Intercourse is
unbearable. She reported dyspareunia that was severe. Reports a
fishy odor and itching that is constant. Also a clear, mucous, vaginal
discharge. She reports regular periods that usually occur the first of
every month. LMP: 10/5/2014. She has had some spotting the last few
days, but has not started. Reports minimal cramping with periods and
a moderate flow of menses. In the past, she has used OCPs and the
contraceptive patch, but is currently on no birth control method.
Gravita: 5 Para:0 Term:0 Abortion: 5 (all 5 abortions were
spontaneous). She reports that her last Pap smear was collected in
2012. She denies dysuria, frequency, oliguria, incontinence, hematuria
or pain with urination. Reports a fishy odor.
Musculoskeletal: No complaints of musculoskeletal problem such as
joint pain or stiffness or changes in range of motion.
Integumentary: Denies any rashes, lesions, nodules, or changes in
hair or nails.
Neurological: denies headaches, syncope, or numbness
Psychiatric: History of depression in the past, but denies any recent
changes in mood.

Endocrine: denies temperature intolerance, tremors, excessive thirst,

and hunger
Hematologic: denies any bleeding, bruising, or weakness
Allergies: Has a history of seasonal allergies, but does not currently
take any medication for treatment. Multiple medication allergies. High
risk for exposure to infected body fluids with unprotected sexual
practices.

Objective Data
Constitutional: Patient is a well-nourished Caucasian female that
appears anxious.
HT: 62 in
WT: 71 KG
BMI: 28
BP: 114/60. HR: 98, T:98.4 R:20, O2:100% RA
Eyes: Pupils equal and reactive to light accommodation, sclera white,
conjunctiva pink, with no drainage present. Vision is intact with no
corrective lenses.
Ears: Outer ear has no lesions or deformities. Light reflex present in
pearl gray tympanic membrane bilaterally.
Nose: No lesions or deformities. Nares patent
Mouth and Throat: Mucous membranes pink and moist. All teeth
present and clean, no ulcers or lesions present. No redness or exudate
in throat.
Neck: Trachea symmetric. Thyroid and lymph nodes non-palpable.
Cardiovascular: S1 and S2 heart sounds present with no murmurs or
gallops noted. Radial and brachial pulses 2+ bilaterally. No peripheral
edema noted. No carotid bruit auscultated.
Breast Exam: Breasts are symmetric. There is no dimpling, nipple
discharge, or retraction. Non-tender and there is no masses palpated
bilaterally.
Respiratory: Breath sounds clear bilaterally with no crackles or
wheezes present. Chest excursion is equal on palpitation.

Gastrointestinal: bowel sounds present in all four quadrants. No

abdominal pain with palpitation. No hepatosplenomegaly.
Genitourinary: Unable to palpate bladder. Mild pain above pubic
symphysis with palpation. NO CVA tenderness.
Pelvic Exam:
External Genitalia: normal hair pattern with no lesions. No
Bartholin cysts or skenes glands noted.
Vagina: Rugated erythematous, inflamed tissues with
normal tone. There is a strong vaginal odor with copious
amounts of thin mucous discharge.
Cervix: No gross lesions, with patent OS in the mid position.
Severe cervical motion tenderness (CMT) on exam.
Uterus: small, firm, midlines, smooth and mobile, tender on
exam.
Adnexae: Non-tender bilaterally with no masses palpated.
Musculoskeletal: Muscoloskeletal examination unremarkable, range
of motion intact in all extremities.
Integumentary: Skin appears pale. Nail beds pink and capillary refill
<3 seconds. No lesions or rashes noted on inspection.
Extremities: No edema or varicosities noted.

Psychiatric: Patient appears anxious with variability in mood.

Hematological: No purpura present. Mucous membrane pink and
moist, no bruising or petechiae present.
Diagnostic Tests:
POC Hemaglobin: 12.5
Pregnancy Test: Negative
Vaginal Discharge Ph: Alkaline reading with a PH of > 4.5
Wet Prep: large number of WBCs and clue cells are present on
microscopic evaluation.
Assessment:
Level of Visit: S0610- annual gynecological examination, new patient.

Differential Diagnosis:
Acute appendicitis- not likely, no associated nausea or vomiting.
Abdominal pain is mild and located in mid abdomen, not over
appendix. No pain on palpation to this area.
Ectopic pregnancy- Unlikely diagnosis. urine pregnancy test was
negative. Menstrual period was on schedule previous month and
patient reports spotting now. No history is ectopic pregnancy in
the past.
Bacterial Vaginosis- possible diagnosis. Positive clue cells on wet
prep exam. Vaginal PH is >4.5 and fishy odor.
Trichomoniasis: unlikely diagnosis. Discharge is not frothy or
yellow/green in color and is not malodorous.
Vulvovaginal Candiasis- Unlikely diagnosis. Discharge is not white
in color.
Chlamydial Infection- possible diagnosis. Patient reports
dyspareunia, abnormal vaginal discharge, and abdominal and
pelvic pain.
Gonorrhea-Possible diagnosis. However, vaginal discharge does
not appear purulent. She has had spotting but no reports of
dysuria.
Pelvic Inflammatory Disease: Likely Diagnosis- CDC
recommendations for diagnosis (Uphold & Graham,2014)
o Meets all minimum criteria (1.experiencing pelvic or lower
abdominal pain, 2. no other cause other than PID can be
readily identified. 3. Cervical motion tenderness is
present.)
o Additional criteria: abnormal cervical or vaginal discharge,
and an abundant number of white blood cells on wet prep.
Ovarian cysts- not likely no tenderness to adnexae noted on
bimanual examination.
Urinary tract infection- not likely. No dysuria or burning with
urination.
Diagnosis:
N73.9: Female Pelvic Inflammatory Disease, unspecified
616.10: Vaginitis and Vulvovaginitis, unspecified (Bacterial
Vaginosis)
Z25.9 Unspecified contraceptive management
Z11.51 screening for papillomavirus
Plan
Pelvic Inflammatory disease and Bacterial Vaginosis
o Medications
Ceftriaxone (Rocephin) 250 mg IM Now

Azithromycin 1 GM PO Now
Clindamycin 300 mg PO BID X 7 days
o Sex Partners
Patient is advised to make all sex partners over the
last 60 days aware of her diagnosis and the need for
STD testing.
Patient advised to refrain from sexual intercourse
until medication is complete and symptoms have
resolved.
o Follow-up
Patient is scheduled to return to clinic in 72 hours for
recheck for improvement.
Informed that if no improvement occurs the patient
may require hospitalization for further management.
Contraceptive Method
o Patient educated that Nuva-Ring will not be the most
appropriate method at this time due to severe vaginal
infection.
o Depo-Provera IM
Indication: for pregnancy prevention
MOA: progestin only contraceptive that inhibits
follicular development and prevent ovulation.
Dosage: 150 MG IM Injection every 3 months
Generic Cost:
Walgreens: $32.01
CVS Pharmacy: 30.86
Walmart: $53.10
Educated that other contraceptive methods will be
needed for the first week after shot is given.
However, patient at this time should be refraining
from sexual practices until infection is cleared.
Patient is advised that contraceptive method WILL NOT prevent
STDs and a form of barrier should be used.
The importance of Self Breast Exams was stressed. Patient also
advised that with a strong family history of breast cancer she
should start mammograms at the age of 35.
Smoking cessation education is provided to patient.
Return to clinic as needed after infection clears and in one year
for annual physical examination.