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Case Study.
History of Present Illness (HPI): Cindy is a 25-year-old Hispanic G1P0010 who presents to the office for
annual gynecologic exam. Her LMP was 1 week ago, and she does not use contraception. The patient
has no current complaints and denies abnormal uterine bleeding. She has never had cervical cancer
screening and is unsure if she received the HPV vaccine. She reports 3 sexual partners in the last 6
months.
Prior medical history: Chlamydia. Prior surgical history: None
Current medications: None. Allergies: None
GYN History: Menarche age 13, cycle length- 7 days- frequency every 28 days- 4-5 tampons per day.
Positive history of chlamydia 1 year ago. Never had cervical cancer screening.
LMP: 1 week ago. Contraception history: None, does not use condoms.
Social history: Lives with a roommate. Works as a bartender. ETOH 3-4 vodka drinks 2 nights/week.
Denies recreational drug use, never smoker.
Family history: Unremarkable.
Review of Systems (ROS): Negative.
Physical Exam (PE)
VS: BP: 110/70, P: 90, RR: 18, T: 98.4, Weight: 122 lbs, Height 5’6”., BMI 19.7
External: Appropriate hair distribution, No lesions, Small, painless lump palpated at left vaginal opening.
Mild swelling noted. Speculum exam: Scant yellow vaginal discharge, no lesions, no cervical motion
tenderness (CMT). Bimanual exam: uterus normal size firm and non-tender. No adnexal masses palpated
bilaterally, nontender. Breast exam normal. Her physical exam is otherwise unremarkable.
Please follow the rubric listed below:
Analyzes subjective and objective data and outlines applicable diagnostic test related to case studies
Identifies differential diagnoses related to case studies (3 differential diagnoses)
Formulate a treatment plan related to case study based on scientific rationale, evidence-based standards of care and practice guidelines. Integrates ethical, psychological, physical, financial issues and social determinants of health in plan
Please use attached template
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