Case #1

Case #1. Debbie.History of Present Illness (HPI): Debbie is a 19-year-old female G1P0010. She presents to your office as anew patient for GYN visit. Her chief complaint is mild lower abdominal pain and a copious amount of vaginal discharge that started a little over 1 week ago. She is sexually active and reports having four male partners in the last six months.Prior medical history: Depression, HSV-2. Prior surgical history: Surgical termination of pregnancy 1 year agoCurrent medications: Lo loestrin Fe. Allergies: NoneOB- GYN History: Surgical TOP x 1. Menarche age 9, cycle length- 7 days- frequency every 28 days- 3 -4tampons per day. Hx of HSV-2. Never had pap smear.LMP: 2 weeks ago normal. Contraception history: OCP since TOP 1 year ago.Social history: Lives parents. Denies ETOH or recreational drug use, never smoker. Graduated highschool. Not in college. Works FT as a waitress.Family history: Mother – depression. Father unknownReview of Systems (ROS): Negative except as noted in HPI.Physical Exam (PE)VS: BP: 112/80, P: 72, RR: 16, T: 98.4, Weight: 110 lbs., Height 54 in, BMI 18.9 kg/m2 General: WDWN female in NAD Abd: Soft, NT/ND, no masses/HSM GU: No external lesions, no erythema. Mucopurulent endocervical exudate visible in theendocervical canal, sample obtained – cervix is friable. Mild CMT, no uterine tenderness, noadnexal tenderness, no masses.DiagnosisBased on the clinical presentation, the most likely diagnosis is Cervicitis, with concern for an underlying sexually transmitted infection (STI), most likely Chlamydia trachomatis and/or Neisseria gonorrhoeae. The findings also suggest early or mild Pelvic Inflammatory Disease (PID), given the presence of cervical motion tenderness (CMT). Rationale for DiagnosisKey Clinical Findings Supporting Cervicitis/PIDFindingClinical Significance