Case Study

Case Study 1

Charlene Baja is a 22-year-old G0 P0 presents to the clinic today for burning and discharge for 1 week. She states her boyfriend recently found out he was positive for chlamydia. She denies any other partners besides him.  Her medical history is remarkable for anxiety and depression.  Her surgical history is unremarkable. Her social history includes social alcohol, but she denies tobacco and any recreational drugs.  She has no known drug allergies and takes a multivitamin and Sprintec daily for oral contraception. Her health history reveals that her mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia.  Charlene has one brother with no medical history.

· Height 5’ 5” Weight 148 (BMI 24.6), BP 132/68 P 62

· HEENT:  WNL

· Neck: lymph nodes grossly normal

· Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam

· Breast: normal breast exam

· Abd: WNL

· VVBSU: WNL

· Cervix: firm, smooth, yellow watery discharge in large amount present

· Uterus: RV, mobile, non-tender

· Adnexa: WNL