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PATIENT PRESENTATION

Chief Complaint

“I’m having some issues with my private parts.”

History of Present Illness

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.

Past Medical History

T2DM, HTN, HLD

Surgical History

Adenoidectomy

Family History

Noncontributory

Social History

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.

Allergies

NKDA

Home Medications

Metformin 1000 mg PO BID W/F

Empagliflozin 25 mg PO daily

Lisinopril 20 mg PO daily

Atorvastatin 20 mg PO daily

Copper IUD inserted 2 months ago

Physical Examination

Vital Signs

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

General

Slightly overweight, but well-groomed woman

Genital/Rectal

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.

Laboratory Findings

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Na = 136 mEq/L

HbA1c = 6.8%

K = 4.1 mEq/L

TC = 126 mg/dL

Cl = 100 mEq/L

LDL = 68 mg/dL

CO2 = 27 mEq/L

HDL = 54 mg/dL

BUN = 10 mg/dL

TG = 98 mg/dL

SCr = 0.6 mg/dL

Glu = 106 mg/dL

Ca = 9 mg/dL

Urinalysis

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

Serum Pregnancy Test

Negative

“Whiff” Test

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