Juliana Mirabelles
25 y/o
CC: Pain with urination
HPI: 25 year old female p/w 3 day history of dysuria, urinary frequency as well as mucopurulent vaginal
discharge. She denies fever, chills, myalgia. She has a previous hx of UTI, smoking, and multiple sex
partners with some unprotected sex.The pain is alleviated by a warm bath and increased with standing.
Physical exam shows cervical friability.
PMHX
Allergies: NKDA
Other active problems: None
Medical, surgical, obstetric: None just dental fillings
Preventative health: Last Pap smear negative a few years ago: no Hx of abnormal results
Previous screening for STDs
Immunizations: No previous HPV vaccination
General immunization status: the patient thinks she is up to date.
Rx: Oral contraceptive pills (OCP): ethinyl estradiol/drospirenone
Ibuprofen for menstrual cramps
FHx: Mother: diabetes mellitus (DM)
Father: hypertension (HTN), coronary artery disease (CAD), hyperlipidemia
Older sister: Alive and well
SHx: Works as a consultant; travels frequently
Alcohol: 1 to 2 times per week; 4 to 5 drinks per occasion
No other substance use
Previous-smoker status; approximate 2-pack-year Hx
ROS:
General- Tired due to lack of sleep related to increased urination
Skin/hair/nails- Negative
HEENT- Negative
Breast- Negative
Cardiovascular- Negative
Respiratory- Negative
Gastrointestinal- Negative
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