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SUBJECTIVE DATA (S):IDENTIFYING DATA:Initials: S.C.Age: 21 yearsRace: CaucasianGender: FemaleCHIEF COMPLAINT (CC): Patient c/o “whitish-gray discharge that has a fishy-smelling odor x 1 1/2 months”. HISTORY OF PRESENT ILLNESS (HPI): Patient is a healthy, physically active female with no known medical history. Patient needs yearly PAP smears and has been getting them since she became sexually active when she turned 18 years old. Previous PAP was normal and done at South Baldwin OBGYN in 2013. Patient states she has had a whitish-gray discharge that has a fishy-smelling odor for about 1 ? months. She explains she would like STD testing. Patient also states her cycle is about to start and she is having some cramping. Denies any other s/s, no pain, no itching. She states she only has male partners, currently 2, last exposure 4 days ago with condom usage. She states she has had sexual intercourse with a total of 5 people in her lifetime. She is not currently taking birth control and does not want to start taking contraceptives at this time. PAST MEDICAL HISTORY (PMH):Allergies: NKDACurrent medications: noneAge/health status: 21 yearsAppropriate immunization status: Tdap, Hep B, MMR, Varicella, HPV up to date. She has also had the flu vaccine for this season. Previous screening tests result: PAP 2013, normal. Will not need mammogram until 40 yo unless SBE reveals problem.Dates of illnesses during childhood: N/AMajor adult illnesses: N/AInjuries: N/AHospitalizations: N/ASurgeries: Patient denies having any surgeryFAMILY HISTORY (FH): Father is 54yo and has a medical history of pre-HTN. Mother is 53yo and has no known significant medical history. Brother is 19yo and has no known significant medical history. Maternal grandmother is 82yo and has a medical history of hypothyroidism. Maternal grandfather is deceased and has a medical history of Type 2 diabetes, MI, CAD, and HTN. Paternal grandmother deceased and has a medical history of melanoma. Paternal grandfather is deceased and has a medical history of MI, CAD, HTN, and kidney disease.SOCIAL HISTORY (SH): She is single and has no children. Currently working at a clothing store at the mall while attending college. She is independent with her ADLs and lives with a friend. She states she goes to the gym 3 days a week. She does not use tobacco. No illicit drug use. She drinks alcohol socially on weekends. She drinks caffeine (coffee, tea, or soda) 1-3 times daily. She is sexually active. She does wear her seatbelt.REVIEW OF SYSTEMS (ROS):Constitutional symptoms- Patient denies fever, fatigue, chills, malaise, night sweats, unexplained weight loss or weight gain, loss of appetite. Eyes- Patient denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma, peripheral visual changes, and dry eyes. Patient states he does wear corrective lenses and has for the last 20 years. Date of last eye exam was in 2013.Ears, nose, mouth, and throat- Patient denies vertigo, sinus problems, headaches, epistaxis, dental problems, oral lesions, hearing loss or changes, nasal congestion, sore throat, hoarseness. Date of last dental visit was about 8 months ago. She brushes her teeth twice a day and uses dental floss. Cardiovascular- Patient denies any history of heart murmur, chest pain, palpitations, dyspnea, activity intolerance, varicose veins, edema. She exercises 3 times per week. Respiratory- Patient denies cough, SOB, difficulty breathing, wheezing, pain with inspiration, chest tightness, history of respiratory infections, exposure to TB, hemoptysis. Gastrointestinal- Patient denies dysphagia, reflux, pyrosis, loss of appetite, bloating, nausea, vomiting, diarrhea, constipation, hematemesis, abdominal or epigastric pain, hematochezia, change in bowel habits, food intolerance, flatulence, hemorrhoids. Patient states she tries to eat healthy, well-balanced meals. Genitourinary- Patient denies urgency, frequency, dysuria, suprapubic pain, nocturia, incontinence, hematuria, history of stones. Patient has frequent sex with 2 partners, sometimes using condoms and sometimes being unprotected. She has been having a whitish-gray discharge from her vagina that has a fishy-smelling odor for about 1 ? months. Her period began at age 13. She has regular monthly periods. Patient denies pain or heavy bleeding. She has never been pregnant. LMP 10/2014. Musculoskeletal- Patient denies back pain, joint pain, muscle cramps, neck pain or stiffness, changes in ROM. She states she exercises about 3 times a week. She does wear her seatbelt. Integumentary- Patient denies itching, uritcaria, hives, nail deformities, hair loss, moles, open areas, bruising. Breasts: Patient denies practice of self-breast exam, breast tenderness, masses, lumps, pain, discharge, dimpling, or skin changes. Neurologic- Patient denies weakness, numbness, headache, tingling, memory difficulties, involuntary movements or tremors, syncope, stroke, seizures, paresthesias.Psychiatric- Patient denies nightmares, mood changes, anxiety, depression, nervousness, insomnia, suicidal thoughts, exposure to violence, or excessive anger.Endocrine- Patient denies cold or heat intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair or nail texture, unexplained change in weight, changes in facial or body hair, changes in hat or glove size, use of hormonal therapy.Hematologic/lymphatic- Patient denies unusual bleeding or bruising, lymph node enlargement or tenderness, fatigue, history of anemia, blood transfusions. Allergic/immunologic- Patient denies exposure to blood or body fluids, use of steroids, or immunosuppression in self or family. She is up-to-date on Hep B vaccine. OBJECTIVE DATA (O):Constitutional- VS: Temp- 97.9, BP- 112/78, HR- 72, RR- 18, O2 sat- 100%, Height- 5’4”, Weight- 122.6 lbs, BMI- 20.5; General Appearance: healthy-appearing, well-nourished, and well-developed. Level of Distress: NAD. Ambulation: ambulating normally.Eyes- sclerae white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally. Extraocular movements intact.Ear, Nose, Throat- Ears: external appearance normal-no lesions, redness, or swelling; on otoscopic exam tympanic membranes clear. Hearing is intact. Nose: appearance of nose normal with no mucous, inflammation, or lesions present. Nares patent. Septum is midline. Mouth: pink, moist mucous membranes. No missing or decayed teeth.Throat: no inflammation or lesions present. Tonsils WNL- no erythema, ulcers, masses, exudate, inflammation.Cardiovascular- S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubsCarotid Arteries: normal pulses bilaterally, no bruits presentPedal Pulses: 2+ bilaterallyExtremities: +2 edema in RLE; no cyanosis, clubbing, less than 2 second refill Respiratory- Even and unlabored. Clear to auscultation bilaterally with no wheezes, rales, or rhonchiGastrointestinal- abdomen soft and nontender to palpation, nondistended. No rigidity or guarding, no masses present, BS present in all 4 quadrantsGenitourinary- No bladder distention, suprapubic pain, or CVA tenderness. External genitalia normal, no gross lesions. Speculum exam: Vagina- healthy mucosa, no gross lesions, whitish-gray discharge noted, fishy-smelling odor. Cervix- no lesions. Wet prep showed a positive whiff test, TNTC clue cells/HPF, no lactobacilli, no hyphae or spores, no trichomonads, and few WBCs. Musculoskeletal- Joint stability normal in all extremities, no tenderness to palpation in all other extremities. Normal ROM and muscle strength, no scoliosis noted. Ambulates normally.Integument/lymphatic- Inspection: No scaling or breaks on skin, face, neck, or arms.General palpation: no skin or subcutaneous tissue masses present, no tenderness, skin turgor normalFace: no rash, lesion, or discoloration presentLower Extremities: no rash, lesion, or discoloration presentUpper Extremities: no rash, lesion, or discoloration presentNeurologic- Grossly oriented x3, communication ability within normal limits, attention and concentration normal. Sensation intact to light touch, gait within normal limitsPsychiatric- Judgment and insight intact, rate of thoughts normal and logical. Pleasant, calm, and cooperative. Patient appears to be happy/content. Hematologic/immunologic- Lymph nodes not palpable, no tenderness or masses present, no bruisingDIAGNOSTIC TESTS:Cancer screening PAP smear: PendingWet prep: positive whiff test, TNTC clue cells/HPF, no lactobacilli, no hyphae or spores, no trichomonads, and few WBCsASSESSMENT (A):Z12.4: Cancer screening PAP smearNormal female exam and PAP performed74162: Bacterial vaginosisWhitish-gray discharge from vagina with a fish-smell odor; Wet prep showed a positive whiff test, TNTC clue cells/HPF, no lactobacilli, no hyphae or spores, no trichomonads, and few WBCs which indicates bacterial vaginosisDifferential Diagnoses:Gonnorhea, 647.13Whitish-gray discharge with a fish-smell odor, frequently has sex with multiple partnersRefuting data: Wet prep confirmed bacterial vaginosisChlamydia, 0099.59Whitish-gray discharge with a fish-smell odor, frequently has sex with multiple partnersRefuting data: Wet prep confirmed bacterial vaginosisTrichomoniasis, 131.01Whitish-gray discharge with a fish-smell odor, frequently has sex with multiple partnersRefuting data: Wet prep confirmed bacterial vaginosisYeast infection, 75564Whitish-gray discharge with a fish-smell odor, frequently has sex with multiple partnersRefuting data: Wet prep confirmed bacterial vaginosisPLAN (P):Flagyl 500mg PO bid x 7 daysPap smear was performed with no difficulties. Sample was sent to LabCorp; results pending. Patient is aware that she will receive results in the mail at home. Patient will be contacted by the clinic if it is abnormal.Medication profile: FlagylIndication: anaerobic bacterial infections, sexually transmitted diseases, bacterial vaginosis, colorectal surgical infections, trichomoniasis, amebiasis, giardiasis, gardnerella infections, helicobacter Pylori infection, nongonococcal urethritis, pelvic inflammatory disease, Crohn’s diseaseMOA: Metronidazole exerts antibacterial effects in an anaerobic environment by the following possible mechanism: Once metronidazole enters the organism, the drug is reduced by intracellular electron transport proteins. Because of this alteration to the metronidazole molecule, a concentration gradient is created and maintained which promotes the drug's intracellular transport. Presumably, free radicals are formed which, in turn, react with cellular components resulting in death of the bacteria.Dose: Nonpregnant women500 mg PO BID x 7 days, OR 2 g PO qDay single dose, OR Extended-release: 750 mg PO qDay x 7 daysPregnant women500 mg PO BID x 7 days, OR 250 mg PO TID x 7 days Brand name/generic: Flagyl, metronidazolePrices for 14 tablets of metronidazole 500mg-Publix: $15 cash or $11.25 with coupon-Wal Mart: $11.34 with free discount-Target: $15 cash or $11.25 with coupon-Walgreens: $16 cash or $9.66 with couponOutside testing: Pap smear, pendingFollow up: 1 year and as neededConsultation/referral: N/APatient Education:-Explain what bacterial vaginosis is: Bacterial vaginosis is also called BV. The vagina normally has bacteria or germs. Some germs are good and others are bad. With BV, there are more bad germs than good ones. Too many bad germs cause problems like bad odor, pain, itchiness, or fluid from the vagina. BV is the most common vaginal disease in women, but is not a sexually transmitted disease or STD. You are more likely to get BV if you are sexually active and pregnant.-Use good body cleaning habits. Do not douche.-Limit the number of sex partners you have. Use condoms and practice safe sex.-Do not wear clothes that may hold moisture, such as nylon or polyester. Wear loose-fitting pants. Avoid tight clothing.-Return to the office if you experience any of the following:Signs of a very bad reaction, such as wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat. Go to the ER right away.Signs of infection, such as a fever of 100.4°F (38°C) or higher, chills, pain with passing urine, or anal itching or pain.Signs of any yellow or green vaginal dischargeBelly or back pain, throwing upRash or lesionsYou are not feeling better in 2 to 3 days or you are feeling worse- Avoid beer, wine, or mixed drinks while taking flagyl. Do not take alcohol for at least 72 hours after the last dose. Drinking alcohol or products that have alcohol, such as cough syrup, may cause cramps, upset stomach, headaches, and flushing.-Begin performing self-breast exams on a monthly basis.-Consider thinking about contraceptive options in addition to condom usage if she continues to be sexually active. ................
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