Patient Information:
Initials: D. O. Age: 25 Sex: Female Race: African American
(AA)
SUBJECTIVE:
Chief Complaint (CC): “I have an increased vaginal discharge with severe itching and irritation
for 2 weeks.”
History
...
Patient Information:
Initials: D. O. Age: 25 Sex: Female Race: African American
(AA)
SUBJECTIVE:
Chief Complaint (CC): “I have an increased vaginal discharge with severe itching and irritation
for 2 weeks.”
History of Present Illness (HPI): 25Y/O AA female visits the clinic with complaints of increase
vaginal discharge, thin gray, white or greenish color, fishy smell, severe itching, lower abdominal
pain and back pain started 2 weeks. She reports pain scale on both ailments as 8/10 intermittently
but got relieved after taking OTC medication Tylenol 500mg every 6 hours as needed. The
patient verbalized no relieve for vaginal discharge and itching. Also, the patient is here for the
prenatal follow-up. The patient is G3P1SAB1, LMP-4/8/2019, EDD-1/13/2020, 36weeks
gestation of pregnancy. She denies any vaginal bleeding, no leakage of fluid, no contractions, no
fever, no urinary frequency, no painful urination, and no painful intercourse. She is sexually
active with two partners and do not use condom.
OB/GYN History:
Menstrual History:
Age at menarche – 13 years
LMP – 4/8/2019
Menstrual Pattern:
Cycle length: 30 days
Duration of flow: 4 to 5 days in a month
Amount of flow: Moderate
Associated pain: None
Intermenstrual bleeding: None
Perimenopause/Menopause: None
Contraception:
Current method: None
Previous methods: Birth control oral pills
Cervical & Vaginal cytology:
Most recent Pap smear– November 6, 2017
History of abnormal Pap smear – Not applicable
Infections:
History of Chlamydia in the past-Treated
No history of pelvic inflammatory disease
Fertility/Infertility:
Desire for future fertility: Yes
Sexual History:
Type:
Heterosexual, sexually active, single partner, unprotected sex
Denies history of sexual abuse or assault
Obstetric History:
G – 3, P – 1, T – 1, A – 1, L – 1
Maternal, fetal, or neonatal complications: None
Past Medical History (PMH):
Current or Past illnesses: HTN, Asthma, and mild Anemia. Pap smear done on
7/8/2019. Patient immunization is up-to-date.
Hospitalizations: None
Past Surgical History:
Past gynecologic surgeries: None.
Past non-gynecologic surgeries: None
Medications and Allergies
Prescribed Medications:
Tylenol 500mg 1 tab Q 6hrs as needed for pain -OTC
Albuterol inhaler inhaled 2 puffs orally Q 4-6hrs PRN for cough/wheezing/shortness of
breath.
Over-the-counter medications: Tylenol 500mg 1 tab Q 6hrs as needed for pain
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