SUBJECTIVE

Name: 0175ap
Age: 28
Race: Caucasian
Gender: Female
Marital Status: Single
Chief Complaint: Establishing care, yearly exam, to include physical exam, breast exam
education, pelvic exam, pap smear, STD testing, and counseling as needed.
History of Present Illness: AP is a 28 year old white female who presents to the health
department to establish care for birth control with current acute complaints of itching
and burning. Pt states, I think I have a yeast infection. Pt reports that for the past 3
weeks she has had burning and itching in her vagina with no discharge or odor. She
reports that she tried a generic monostat 2 days after onset of symptoms and began to get
a little better but then became worse after sexual intercourse the following week. Pt
reports normal menstrual periods with no spotting in between periods. Pt would also like
to get started on birth control as she states sex with her boyfriend has become more
frequent and she does not wish to become pregnant at this time.
location: burning and itching to vagina
Severity: Denies any other pelvic pain, states she has burning especially 1-2 days after
intercourse.
timing: Began two weeks ago after intercourse
setting: has not gone away in two weeks, gets worse 1-2 days after sex.
alleviating and aggravating factors: gets worse after sex, was getting better after
generic monostat but has since had no improvement.
associated signs and symptoms: denies odor, pelvic pain, or external rash.
Past Medical History:
Allergies: NKDA
Current Medications: Tylenol and Ibuprofen PRN,
Age/Health Status: pt reports I have not had any health issues that I know of
Appropriate Immunization Status: Remarks UTD
Previous Screening Test Results: Reports no abnormal pap smears in the past, denies
history of STD denies any other screening exam, does not wear corrective lenses,
Major Adult Illnesses: Denies
Significant Childhood Illnesses: Had chickenpox at age 5, onset of menarche was 11
Hospitalizations: Denies any adult hospital admissions
Surgeries: Denies
Family History:
Mother: 53 Hypothyroidism,
Father: 54; Hypertension, COPD

Social History:
Single, Lives in apartment with boyfriend
Lifetime Sexual Partners 3, sexual debut 15
Level of Education: High school diploma
Currently works full time worker at restaurant
No firearms in the home, smoke alarms used.
Exercise: States she likes to jog when she has time
Religious preferences: none stated
Habits: social smoker only smokes when she is drinking, Denies drugs use, Alcohol
once or twice a week when she goes out to the bar. Denies excessive alcohol use.
Resources: Medicaid Family Planning
Review of Symptoms:
General Appearance: Pt appears in good health, hair nails and skin look to be well taken
care of, pt is dressed appropriately
Eyes: pt reports normal eye exams throughout life, denies any symptoms of double or
blurred vision. No redness noted
ENMT: Ears: hearing acuity normal, denies pain to ears, Nose: Sense of smell intact, no
deviation in septum, reports sinus congestion in the mornings. Mouth: smoker, teeth
appear normal and intact. Pt reports brushing 1-2 times daily and does not floss, Throat:
no sore throat reported, no odor noted, No redness noted
Neck: Thyroid palpated when swallowing, no masses noted, no tendereness to neck
Cardiovascular: Reports no difficulty with exercise denies chest pain palpitations, or
activity intolerance. Denies edema
Respiratory: negative cough dry; negative shortness of breath, negative history of chronic
respiratory diseases.
Gastrointestinal: reports normal balanced diet. Denies food intolerance, nausea, vomiting,
heart-burn, abdominal pain, normal bowel habits, denies hemorrhoids at this time.
Genitourinary: Denies urinary symptoms of nocturia, dysura, incontinence.
Female: reports regular menstrual pattern, pregnancy hx: G0P0, LMP 3 weeks prior to
visit, contraceptive use, not using any at the moment last pap smear: 3 years prior at a
different facility, here for one today.
Musculoskeletal: reports good physical strength with no limitations in mobility, uses
seatbelts all the time, denies neck stiffness, joint pain or swelling, , denies back pain,
denies change in ROM, pt denies body ache or any myalgias. No limitations in work
habits
Integ: reports avoiding sun exposure when possible, does wear sunscreen when walking
outside , does not regularly assess her skin, denies rash, nail deformity, hair loss, bruising.
Infrequent in breast examination
Neurological: denies muscle weakness, syncopy, stroke, seizure, paresthesias, tremor,
loss of memory, or severe headaches.
Psychiatric: denies nightmare, mood change, depression, anxiety, insomnia
Endocrine: Denies heat or cold intolerance polydipsia, polyphagia, polyuria, changes in
skin hair or nails, reports mother has hypothyroidism.

Hematologic: denies unusual bruising, bleeding fatigue, transfusion history, cannot

remember any significant lab values related to blood
Allergic: Denies any food allergies or medication allergies, denies recreational allergies

OBJECTIVE
Constitutional: Temp: 98.0 BP: 110/75 Pulse: 76, Ht: 65 in Wt: 183lbs
General Appearance is fair, general hygiene is within normal limits
Eyes: no redness noted, pupils equal and reactive to light, conjuctiva are nomal, no
jaundice noted. No drainage noted.
ENTM: Ear canal appears red bilaterally, tympanic membranes are dull with scarring to
lower edge. No perforation noted. No external ear tenderness or palpable tenderness
noted. No drainage from the ear noted.
Nose: No drainage noted., nostrils appear patent with no deviation in septum. Nose color
is normal. No irritation of nostril lumen noted.
Mouth and Throat: dentition normal, mucous membranes moist, lips and gums normal
with no lesions, uvula midline, no odor from mouth, throat appears red and roof of mouth
has redness just anterior to the uvula. No exudates noted to back of throat. Tongues is
midline and of normal size.
Neck: Supple, no thyromegaly or palpable mass, anterior, posterior cervical, and
submandibular lymph nodes are not swollen upon palpation, no neck tenderness noted.
No redness noted to neck. No evidence of JVD
Cardiovascular: Heart Sounds Normal S1, S2, no murmurs, clicks, gallops, Peripheral
pulses intact, no edema noted
Respiratory: No Cough noted, respiratory effort is unlabored and regular, lung sounds
clear with no wheezes, rales, or rhonci. No sputum reported
Gastrointestinal: Bowel Sounds Present, No abdominal tenderness noted, no masses of
abdomen noted, no ascited or hernia noted. No abdominal scarring noted.
Gentiourinary: pt denies any dysuria or genitourinary concerns
Musculoskeletal: no bony abnormality noted. Pt denies any pain to extremeties, back,
pelvic cage.
Integumentary: no lesions noted to visible fields, no rash noted, skin is warm and dry
with good skin turgor
Neurological: pt alert and oriented x3. No gross neurological abnormalities noted on
exam. Gait is normal.
Psychiatric: Behavior is appropriate and memory intact
Hematological: no evidence of bruising or bleeding, no jaundice noted.
Pelvic exam: External genitalia show no lesions or redness, vaginal walls are moist and
pink with no lesions or redness, milky white discharge noted, no odor noted on exam.
Cervix is round, pink and smooth with no lesions with white discharge noted. Ovaries not
palpated with bimanual exam, uterus is firm smooth moveable and non-tender.
Assessment

Visit Level: 99203 Level 3 multiple dx and visit 30 minutes

Differential Diagnosis (most probable to least)

1. 616.10 Vaginitis/vulvitis, unspec.

2. 616.1 Vaginitis and vulvovaginitis
3. 112.1 Moniliasis, vulva/vagina
4. 098.15 Gonococcal cervicitis (acute)
5. 131 Trichomoniasis
6. 131.01 Trichomonal vaginitis
7. 483.1 Chlamydia
8.180.9 Cervix uteri, unspecified (Neoplasm)
9. 054.11 Herpetic vulvovaginitis
Tests:
84703 Urine Pregnancy Test
88175 Pap Smear
46845, 46855 Cervical STD screening
87210 Wet Prep

PLAN
1,2,3,5. Wet Prep examination microscopy
Results: positive for bacterial vaginitis no evidence of budding, no evidence of
trichomonal growth
4,5,6,7. STD screening (send off lab)
8. Results of Pap Smear (send off lab)
UPT completed due to patients consideration of starting birth control
INTERVENTION
1. Results of Wet Prep, STD Screening, and Pap Smear,
2. Antibiotic Therapy (Flagyl 500mg PO BID x 7 days)
3. Smoking cessation counseling (social smoker)
4. establish follow-up for 7 days and 6 months for birth control re-fill and establish yearly
exams
5. Avoid Alcohol while taking Flagyl
6. Place patient on Progestin only birth control, NorQD pt to begin after next menses
7. Self Breast Examination education (monthly schedule and technique)
Medication information
Flagyl (metronidazole)
Indication: EBP firstline treatment for bacterial vaginitis
MOA: inhibits nucleic acid synthesis by disrupting DNA and causing strand breakage,
amebicidal, bactericidal, thrichomonacidal
Dosage in this diagnosis is 500mg PO BID x 7 days, Also available in extended release
and IV doasages,

Available in both name brand and generic

Cost: available free at health department for patients with Medicaid Family Planning
Publix generic is $14.95 with Publix Care $11.95 with no other insurance coverage
Target Pharmacy cost $15.49
Patient education needs:
Current Treatment
Avoiding alcohol while taking flagyl, side effects of medication
Finish all medication even if feeling better sooner (unless allergy)
Begin birth control after next menses, until then using other forms of birth control
Avoid sexual intercourse until symptom improvement
Health Promotion:
Smoking cessation counseling
Post-coital urination
Encourage diet and exercise (this patient BMI is elevated)
Health Maintenance / Disease Prevention:
Self- Breast exam monthly
Pap smear ever 3 years unless abnormal then ever year
STD testing annually or when symptomatic
Avoid sitting in bathtub, avoid douching, avoid wearing wet underpants for any
considerable time including bathing suits, condom use, post-coital urination
Evaluation
1. Improvement in symptoms at 7-day evaluation.
2. Discuss results of Pap smear and STD screening at follow-up
3. Pt reports performing monthly self breast exams at 6 month follow-up
4. treatment of any other disease noted with result of pap smear and STD screening