Skip to Main Content

PATIENT PRESENTATION

Chief Complaint

“I’ve noticed some discharge in my underwear.”

History of Present Illness

TP is a 23-year-old black female who presents to the family medicine clinic with complaints of unusual discharge. She reports a frequent sensation of urination and mentions that she has been having odorless vaginal discharge that is different than usual. Upon questioning she mentions being nervous that she may have an STD because she had unprotected vaginal intercourse with a young man after a fraternity party about 2 weeks ago. Since then, she heard rumors that this particular gentleman has a history of multiple sexual partners, but she was not concerned until noticing the discharge 2 days ago.

Past Medical History

Asthma, prior ankle injury

Surgical History

Tonsillectomy

Family History

Mother and father with HTN

Social History

Active as a college basketball player; occasionally smokes marijuana; (–) tobacco; (+) EtOH (beer and liquor most weekends)

Allergies

Doxycycline (swelling of lips and tongue as a teenager)

Home Medications

Acetaminophen 500 mg, two tablets PO q4-6h PRN pain

Ibuprofen 200 mg PO q4-6h PRN pain

Albuterol metered-dose-inhaler 2 puffs q4h PRN shortness of breath and prior to exercise

Ethinyl estradiol and norgestimate (Ortho Tri-Cyclen Lo) one tablet PO daily

Physical Examination

Vital Signs

Temp 98.6°F, P 68, RR 18 breaths per minute, BP 116/70 mm Hg, pO2 97%, Ht 5′8″, Wt 72.7 kg

General

Well developed, well-nourished female in no acute distress

HEENT

Non-contributory

Pulmonary

Denies shortness of breath

Cardiovascular

NSR, no m/r/g

Abdomen

Soft, non-distended, non-tender, (+) bowel sounds

Genitourinary

Normal female genitalia, denies abnormal bleeding, (+) vaginal discharge

Neurology

(+) headaches 1–2 times a week, A&O ×3

Extremities

Noncontributory

Laboratory Findings

Favorite Table | Download (.pdf) | Print

Na = 136 mEq/L

Hgb = 12.9 g/dL

Ca = 8.5 mg/dL

K = 4.1 mEq/L

Hct = 37.3%

Mg = 2.1 mEq/L

Cl = 98 mEq/L

Plt = 256 × 103/mm3

Phos = 3.5 mg/dL

CO2 = 26 mEq/L

WBC = 6.3 × 103/mm3

AST = 18 U/L

BUN = 12 mg/dL

ALT = 22 U/L

SCr = 0.9 mg/dL

T ...

Pop-up div Successfully Displayed

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