Debbie

Debbie. History of Present Illness (HPI): Debbie is a 19-year-old female G1P0010. She presents to your office as a new 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 ago Current medications: Lo loestrin Fe. Allergies: None OB- GYN History: Surgical TOP x 1. Menarche age 9, cycle length- 7 days- frequency every 28 days- 3 -4 tampons 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 high school. Not in college. Works FT as a waitress. Family history: Mother – depression. Father unknown Review 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 the endocervical canal, sample obtained – cervix is friable. Mild CMT, no uterine tenderness, no adnexal tenderness, no masses.Provide referencs and in text citations