H&P 

History  

Identifying Data:   

Full Name: VA

Address: N/A   

Date of Birth: N/A   

Date & Time: 10/10/2023, 11:00 am   

Location: All Care Family Medicine  

Religion: N/A   

Source of Information: Self 

Reliability: Reliable   

Source of Referral: Self   

Mode of Transport: N/A   

Chief Complaint: “I’ve had vaginal itching and burning” x 1 week.

23 y/o female with no significant past medical history presents today for vaginal itching and burning for 1 week. Patient also notes some white discharge when she wipes. Pt believes symptoms are due to norethindrone acetate which was given for amenorrhea, so pt discontinued for last 2 days and has yet to get menses. Pt has not tried any OTC medications. Denies changes in or new sexual partners, fishy odor, recent antibiotic use, hematuria, flank pain, abdominal pain, fever, chills, nausea, vomiting, diarrhea, SOB, or chest pain.

Initial DDx: 

Candida vulvovaginitis

Cystitis

STI

Nephrolithiasis

Past Medical History: 

Amenorrhea

Childhood Illnesses- N/A   

Immunizations – Up to date

Screening test and results – pap smear, normal

Past Surgical History:  

No past surgical history.  

Denies any blood transfusions.   

   

Medications:  

None

Allergies:  

NKDA   

   

Family History:  

Mother – alive, h/o DM

Dad – alive, h/o DM

Denies family h/o cancer, asthma, kidney disease.

   

Social History:  

Patient lives with parents.    

Habits –Admits to drinking 1 cup of coffee occasionally. No history of smoking, alcohol abuse, or history of illicit substances. 

Travel – No recent travel.   

Diet – Has a well-balanced diet.   

Exercise – Denies exercise.   

Safety measures – Admits to wearing a seatbelt.   

Sexual Hx – Denies h/o STIs. 

Review of Systems:  

General – Denies fever, recent weight loss or gain, chills, night sweats, loss of appetite or generalized weakness/fatigue.   

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.    

Head – Denies headache, head trauma.    

Eyes – Denies eyelid swelling, painful eye movements, visual disturbances, eye redness, lacrimation, pruritus. Does not wear glasses. 

Ears –Denies ear pain, deafness, discharge, tinnitus or use of hearing aids.    

Nose/sinuses –Denies runny nose, discharge, epistaxis, or nasal polyps.   

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion    

Breast – Denies lumps, nipple discharge, or pain.    

Mouth/throat –Denies voice changes, sore throat, bleeding gums, sore tongue, mouth ulcers, or use dentures.  

Pulmonary system –Denies cough, dyspnea on exertion. Denies wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).    

Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.   

Gastrointestinal system – Usually has regular bowel movements daily. Denies nausea, diarrhea and abdominal pain. Denies vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation.    

Genitourinary system – Admits to dysuria and vaginal itching. Denies blood in urine. Denies nocturia, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain.    

Menstrual/Obstetrical – Admits to amenorrhea. Denies breast pain, masses, skin changes, bleeding or discharge from nipple. Pap smear up to date.

Musculoskeletal system – Denies muscle/joint pain from arthritis. Denies deformity or swelling, or redness.   

Nervous – Denies loss of strength or weakness. Denies seizures, headache, ataxia, change in cognition.    

Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.    

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Denies blood transfusion.   

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter    

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.    

   

Physical  

  

General: Female appears clean & casually-groomed, alert & active. Also has good posture and well-developed. Does not appear to be acute distress. 

   

Vital Signs:     BP: (R) 138/88 (sitting)   P:  96 beats/min, regular   

    

R: 18 breaths/min, unlabored  

O2 Sat: 99 % on room air  

   

T: 36.66 degrees C (oral)   

   

Weight: 96.62 kg Height: 161.54 cm       BMI: 37.02 kg/m2

   

Head, Skin, & Nails  

   

Hair: Average quantity and distribution. Black color. Straight texture. No evidence of lice or seborrheic dermatitis.   

Skin: Warm and moist, smooth texture, good turgor.    

Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities   

Head: Normocephalic, atraumatic, non-tender to palpation throughout.   

 

Eye Exam  

   

Eyes – Symmetrical OU. No strabismus, exophthalmos or ptosis.  Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/30 OS, 20/30 OD,  20/30 OU. Visual fields full OU.  PERRLA, EOMs intact with no nystagmus.

Ear Exam  

   

Ears – Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TM’s pearly gray/infarct with light reflex in good position AU.  

Nose & Sinuses Exam  

   

Nose – Symmetrical/no masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/deformities/injection/perforation. No foreign bodies.   

   

Sinuses – Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.  

Mouth & Pharynx  

   

Lips – Pink, moist; no cyanosis or lesions.     

Mucosa – Pink ; well hydrated. No masses; lesions noted. No leukoplakia.    

Palate – Pink; well hydrated.     

Teeth – Good dentition / no obvious dental caries noted.    

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.  

Tongue – Pink; well papillated; no masses, lesions or deviation.    

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.    

Tonsils present with no injection or exudate. Uvula pink, midline, no edema, lesions   

   

Neck Exam  

  

Neck- Trachea midline.   No masses; lesions; scars; pulsations noted.   Supple; non-tender to   

palpation.   FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.   

   

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.    

   

Thorax & Lungs:   

   

Chest – Symmetrical, no deformities, no trauma, Respirations unlabored and no use of accessory muscles noted. Lat to Ap diameter 2:1. Non-tender to palpation throughout.

   

Lungs – No wheezing, rales, stridor, or rhonchi. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.   

   

Cardiac Exam  

   

Heart: Carotid pulses are 2+ bilaterally without bruits. Regular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.    

   

Abdominal Exam: Abdomen flat and symmetric, and no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Pt is non-tender to palpation in all four quadrants. (-) guarding. (-) obturators sign, (-) psoas signs, (-) rebound tenderness. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.   

Pelvic Exam:

Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema. White discharge noted.

     

Neurologic:  

Mental status: Patient is alert. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally.  

Reflexes:  

   

          Biceps        Triceps       Brachioradialis    Patellar       Ankle/Achilles    Babinski   

Right          2+     2+     2+     2+     2+     absent   

Left  2+     2+     2+     2+     2+     absent   

   

Peripheral Vascular: Extremities are normal in color and temperature, no edema. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing or cyanosis. No stasis changes or ulcerations noted.   

   

Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities.  Non-tender to palpation/no crepitus noted throughout. FROM of all upper and lower extremities bilaterally.  No evidence of spinal deformities.     

Labs

Urine Dipstick

Glucose 150

A1c 9.8

CMP

Glucose 211

Lipid Panel

Cholesterol 227

LDL 113

HDL 37

Triglycerides 385

Assessment:  

23 year old female with no past medical history with strong family history of type 2 diabetes mellitus, with vaginal itching and dysuria for 1 week likely due to vulvovaginitis secondary to uncontrolled diabetes. Urine Dipstick with glucose 150. Labs significant A1c of 9.8 and glucose of 211. 

Differential Diagnosis 

• Candida Vulvovaginitis

Plan: 

Will start pt on clotrimazole cream 1% at bedtime for 7 days. Will also start pt on Metformin 500mg twice a day. Start Freestyle libre 14 Day sensor. Will order additional testing for Islet cells this week to determine if pt is type 1 or type 2 diabetic. Start Atorvastatin 10 mg once daily. Order pelvic US for amenorrhea. Patient encouraged to consume a dietary pattern that emphasizes intake of low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits the intake of sweets, sugar-sweetened beverages, and red meats and incorporate exercise as tolerated.