Case #3. Randi. History of Present Illness (HPI): Randi, a 22-year-old female, presents to the

Case #3. Randi. History of Present Illness (HPI): Randi, a 22-year-old female, presents to the clinic with c/o of a 3-day history of thick white vaginal discharge, intense vaginal itching, and dysuria. She reports she is sexually active with 1 partner. No history of STI’s. She had a recent sinus infection and was on amoxicillin x 10 days. Prior medical history: None. Prior surgical history: None. Current medications: Mirena IUD – inserted last year. Allergies: Sulfa Social history: College student. Lives with mother. Denies smoking or recreational drugs. Vapes daily. Family history: Mother alive and well. Father alive and well. Sister – diabetes: uses insulin pump OB- GYN History: Menarche age 13, cycle length 5 days – frequency every 28 days. No history of sexually transmitted infections (STIs). Never had a pap smear. Review of Systems (ROS): As noted in HPI. Physical Exam (PE) VS: BP: 110/70, P: 109, RR: 17, T: 98.9, Weight: 132 lbs., Height 65 inches, BMI 22 kg/m2 • General: AAO x 3, pleasant. • Gynecological: EXTERNAL EXAM: mild erythema, white clumpy discharge. SPECULUM/INTERNAL EXAM: Cervix: normal appearance, no lesions, no bleeding, white discharge, no cervical movement tenderness. UTERUS: normal size, shape, and consistency, normal mobility, nontender. ADNEXA: no masses or tenderness bilateral

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