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“I’m having some issues with my private parts.”
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History of Present Illness
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SP is 42-year-old Caucasian female presenting to her primary care provider for the above complaint. For the past seven days, she has experienced moderate vaginal discomfort, described as a burning/itching sensation around her vulvovaginal area, particularly when she urinates. She reports abnormal amounts of thin discharge from her vagina throughout the day. She is most perturbed by the odor and color of the discharge, which is dark yellow and foul smelling. She is recently divorced and is concerned that these symptoms will impact her social life, as she has began to experience pain during vaginal intercourse and is self-conscious of the odor of her discharge. Her last period was 2 weeks ago.
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G3P2A1. Recently divorced after a 20-year marriage. Currently dating several men and has multiple male sexual partners. Does not use condoms during sexual intercourse. Denies tobacco use. Drinks 4 to 5 alcoholic mixed drinks on the weekends when out with friends.
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Metformin 1000 mg PO BID W/F
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Empagliflozin 25 mg PO daily
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Lisinopril 20 mg PO daily
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Atorvastatin 20 mg PO daily
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Copper IUD inserted 2 months ago
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Temp 98.5°F, P 86 beats per minute, RR 16 breaths per minute, BP 124/72 mm Hg, pO2 99%, Ht 5′8″, Wt 89.8 kg
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Slightly overweight, but well-groomed woman
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Labia minora inflamed and red. No discharge issuing from urethra. Vagina exhibiting small amounts of frothy, thin yellow mucus, which emotes a putrid odor. Cervix completely visualized upon speculum insertion; appears pink with red “strawberry” lesions. Purulent discharge observed around endocervical canal.
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Color—light yellow, Clarity/turbidity—clear, pH—6, Specific gravity—1.005, Glucose—300 mg/dL, Blood—none, Ketones—none, Nitrites—negative, Leukocyte esterase—negative