History

Identifying Data:

ID: 30yof

Address: Brooklyn, NY

Date & Time of Encounter: 3/19/24, 9:10am

Location: Woodhull OB/GYN Clinic

Source of Information: Self

Source of Referral: PCP

Chief Complaint: “I haven’t had a pap smear in many years”

History of Present Illness:

30YOF G3P3003 presents to establish gynecological care, with referral from PCP. Pt estimates she has not received health maintenance gyn care for about 8 years, which is when she estimates her last Pap smear was. Denies h/o abnormal pap results. States she is currently sexually active with only her husband. They do not use any contraception, which Pt declines interest in using. Reports LMP 3/5/24. Pt had HIV and HepB screens at Woodhull earlier this year. Results show HepB non-immune status, and Pt would like to begin vaccine series today. Denies h/o STDs, agrees to GC/CT and syphilis testing in-office today. Pt reports mild vaginal pruritus and increased discharge beginning about 4 days ago, notes that she is in the middle of her menstrual cycle so she believes symptoms may be 2/2 ovulation. Denies foul odor, colored or thick discharge, vaginal lesions, or pelvic pain. Pt notes her maternal grandmother died from “vaginal cancer,” denies family h/o other cancers, including breast.

Past Medical History:

Present chronic illnesses – Denies 

Past medical illnesses – Denies 

Childhood illnesses – Denies 

Immunizations – Pt is not vaccinated against HepB, agrees to begin vaccine series today. Vaccines are otherwise up to date, including annual COVID-19 and annual influenza vaccines.

Screening tests and results – Last PAP smear ~2018, reports normal results. Pt has never undergone mammography or colonoscopy.

Obstetric History: G3P3003, 2xNSVD and 1xCS. LMP: 03/05/2024.

Past Surgical History:

Cesarean Section – age 28, Woodhull Hospital, Brooklyn, NY. No complications.

Denies past injuries or transfusions.

Medications:

Denies use of medications.

Vitamins and Supplement – Daily Women’s Multivitamin, unknown content, unknown dosage, once a day, last dose yesterday AM.

Allergies:

NKDA

Denies environmental or food allergies.

Family History:

Maternal grandmother – Deceased at 74 from “vaginal cancer”

Mother – 59, alive and well

Sister – 25, alive and well

Son – 7, alive and well

Daughter – 4, alive and well

Daughter – 2, alive and well

Social History:

PT has been married to her husband for 8 years. They live together with their three children.

She works part-time at a grocery store.

She denies drinking any alcohol, smoking cigarettes/cigars, or using illicit drugs. 

She reports a mostly sedentary lifestyle, she is not active aside from walking to and from local locations. 

She is currently sexually active with only her husband. Denies history of sexually transmitted diseases. Will undergo STD testing during today’s visit.

Review of Systems:

General – Denies recent weight loss or gain, fever, or recent illness.

Skin – Reports mild vaginal pruritus. Denies vaginal skin changes/lesions.

Breast – Denies tenderness, nipple discharge, dermatological changes, or vascular changes.

Gastrointestinal system – Denies change in appetite, nausea, vomiting, diarrhea, abdominal pain, or blood in stool.

Genitourinary system – Denies urinary frequency or urgency, dysuria, or flank pain.

Menstrual/Obstetrical – G3P3003. LMP 3/5/24. Reports regular menstrual cycle. Reports last Gyn exam was ~8 years ago. 

Psychiatric – Denies anxiety or depressed mood. Denies psychiatric history.

Physical

Vital Signs:    

Wt: 256

Ht: 68

BMI: 38.9

Temp: 98F, oral

Pulse: 63 bpm, regular rate and rhythm 

Resp: 22 rpm, unlabored

Sp02: 100% on room air

BP: 118/84, seated L arm

General: 

Well-nourished and well-groomed Hispanic female that looks her stated age. Attentive and conversational. 

Skin:

Warm & moist, good turgor. Nonicteric.

Lips:

Pink, moist, no cyanosis or lesions. 

Lungs:

Respirations unlabored with no paradoxical respirations or use of accessory muscles noted. Chest expansion symmetrical. 

Abdomen:

Abdomen flat and symmetric with well-healed midline transverse surgical scar on lower abdomen.  

Pelvic/Bi-Manual:

Vulva grossly intact, no lesions noted. Vagina with normal physiologic discharge, no masses, no odors noted. Cervix without lesions, no CMT. Uterus palpable, non-tender, no gross asymmetry noted. Adnexa nontender, non-palpable.

Assessment

30YOF with a healthy GYN assessment. Pap + STD testing pending, and Pt to begin HepB vaccine series today. 

Notable differentials:

1. Pt reports increased vaginal pruritus and clear discharge this week. Gyn exam is normal. Some possible differentials include:
   1. Physiologic leukorrhea
      1. Pt is mid-cycle and likely ovulating. Pt reports some increased whitish/clear discharge with no odor, confirmed on gyn exam. This is consistent with physiologic discharge, which I am very confident is what this Pt is experiencing.
   2. Contact dermatitis
      1. The perineal area can be sensitive to new soaps, fabrics, or other products it contacts, especially because vaginal pH and flora is sensitive. Mild itching and even increased vaginal discharge might be an inflammatory reaction to an irritating contact. There was no skin irritation on exam and PT did not mention any new products, so this is less likely.
   3. Bacterial vaginosis
      1. BV can also present with copious whitish/clear discharge, but usually with an abnormal odor and a more substantial amount than the patient reports, so BV is low on my differential, but important to include.

Problem List and Plan

1. Encounter for Gynecological Health Maintenance
   1. Pap smear
   2. GC/CT testing
   3. Vaginitis Panel
   4. Syphilis testing
   5. RTC in 1 year for annual wellness exam
2. HepB Non-Immune status
   1. Administer Vaccine #1 of Engerix-B/Recombivax HB vaccine series
   2. RTC 1 month for Vaccine #2