Skip to Main Content

PATIENT PRESENTATION

Chief Complaint

“I have painful sores in my genital area and I have been feeling achy.”

History of Present Illness

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.

Past Medical History

Vulvovaginal candidiasis, allergic rhinitis

Surgical History

Appendectomy at age 18

Family History

Father has HTN, mother has T2DM, sister has PCOS

Social History

Lives at home with her parents; enjoys swimming and running; drinks alcohol occasionally; denies tobacco and illicit drug use

Allergies

Penicillin (hives)

Home Medications

Cetirizine 10 mg PO daily

Ethinyl estradiol 0.02 mg and drospirenone 3 mg, one tablet PO daily

Fluticasone furoate (27.5 mcg/spray), one spray in each nostril once daily

Multivitamin, one tablet PO daily

Physical Examination

Vital Signs

Temp 100.04°F; BP 118/74 mm Hg; HR 80 beats/minute; RR 18 breaths/minute; Ht 5′6″; Wt 52.3 kg

General

Well nourished, mild acute distress

HEENT

Normocephalic, atraumatic, PERRLA, EOMI, moist mucus membranes, good dentition

Cardiovascular

NSR, no m/r/g

Abdomen

Soft, non-distended, non-tender, normal bowel sounds

Genitourinary

Small painful unruptured vesicular lesions in the labia majora, redness and inflammation in the surrounding area, tender local inguinal lymphadenopathy

Neurology

Alert and oriented ×3

Extremities

No edema, no petechiae

Laboratory Findings

Favorite Table | Download (.pdf) | Print

Na = 138 mEq/L

Hgb = 15 g/dL

Ca = 8.2 mg/dL

K = 4 mEq/L

Hct = 45%

Mg = 2.3 mg/dL

Cl = 100 mEq/L

Plt = 250 × 103/mm3

Phos = 4.6 mg/dL

CO2 = 28 mEq/L

WBC = 8.2 × 103/mm3

AST ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.