Chief Complaint (CC) “I am here for my annual physical exam and have been having vaginal discharg

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Asked by cmois006128

Chief Complaint
(CC)

“I am here for my annual physical exam and have been having vaginal discharge.”

History of Present Illness (HPI):

32-year-old Hispanic/Latina pregnant lesbian – her pregnancy has been without complication thus far. She has been receiving prenatal care from an obstetrician. She received sperm from a local sperm bank.

Drug HX: 

Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion

Family HX:

She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.

Review or systems:

No fatigue, fever, or chills. No pain or injury. multiple piercings, and tattoos. Old scars related to “cutting”. no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements.

B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98

Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip. CTA AP&L. S1S2 without rub or gallop, benign, normoactive bowel sounds x 4. 

external genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact. no cyanosis, clubbing or edema. intact without lesions masses or rashes. No obvious deficits and CN grossly intact II-XII

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