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“I have painful sores in my genital area and I have been feeling achy.”
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History of Present Illness
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JJ is a 20-year-old Caucasian female who presents to the community health center for evaluation of genital lesions that have been present for two days. The lesions are painful, vesicular, and accompanied by inguinal lymphadenopathy. JJ has never experienced these symptoms before. Upon further questioning, she stated that she experienced pain, tingling, itching, and burning sensation before the appearance of the lesions. She admits to having multiple male sex partners within the past six months while she was studying abroad and stated that her last sexual encounter was a week ago. She and her partners occasionally but not always use barrier methods during sexual intercourse. JJ is also complaining of nasal congestion and sneezing.
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Vulvovaginal candidiasis, allergic rhinitis
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Father has HTN, mother has T2DM, sister has PCOS
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Lives at home with her parents; enjoys swimming and running; drinks alcohol occasionally; denies tobacco and illicit drug use
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Cetirizine 10 mg PO daily
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Ethinyl estradiol 0.02 mg and drospirenone 3 mg, one tablet PO daily
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Fluticasone furoate (27.5 mcg/spray), one spray in each nostril once daily
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Multivitamin, one tablet PO daily
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Temp 100.04°F; BP 118/74 mm Hg; HR 80 beats/minute; RR 18 breaths/minute; Ht 5′6″; Wt 52.3 kg
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Well nourished, mild acute distress
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Normocephalic, atraumatic, PERRLA, EOMI, moist mucus membranes, good dentition
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Soft, non-distended, non-tender, normal bowel sounds
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Small painful unruptured vesicular lesions in the labia majora, redness and inflammation in the surrounding area, tender local inguinal lymphadenopathy
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