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Case #3. Randi.
History of Present Illness (HPI): Randi, a 22-year-old female, presents to the clinic with c/o of a 3-day
history of thick white vaginal discharge, intense vaginal itching, and dysuria. She reports she is sexually
active with 1 partner. No history of STI’s. She had a recent sinus infection and was on amoxicillin x 10
days.
Prior medical history: None.
Prior surgical history: None.
Current medications: Mirena IUD – inserted last year. Allergies: Sulfa
Social history: College student. Lives with mother. Denies smoking or recreational drugs. Vapes daily.
Family history: Mother alive and well. Father alive and well. Sister – diabetes: uses insulin pump
OB- GYN History: Menarche age 13, cycle length 5 days – frequency every 28 days. No history of
sexually transmitted infections (STIs). Never had a pap smear.
Review of Systems (ROS): As noted in HPI.
Physical Exam (PE)
VS: BP: 110/70, P: 109, RR: 17, T: 98.9, Weight: 132 lbs., Height 65 inches, BMI 22 kg/m2
• General: AAO x 3, pleasant.
• Gynecological: EXTERNAL EXAM: mild erythema, white clumpy discharge. SPECULUM/INTERNAL
EXAM: Cervix: normal appearance, no lesions, no bleeding, white discharge, no cervical
movement tenderness. UTERUS: normal size, shape, and consistency, normal mobility,
nontender. ADNEXA: no masses or tenderness bilaterally.
Case # (3 ) Randi and Descriiption of the Case Chosen with template.
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