JC is a 20- year-old female G0P0AB0 who presents to the clinic today for annual well woman exam. She states she also have lesions on her vagina. The patient appears to be in no distress. She is unaware of any exposure to STDs. Patient denies any fever, nausea, vomiting, abdominal pain, cramping, vaginal bleeding, vaginal discharge, diarrhea, constipation, change in stool, or hematuria. She rates pain on exam as 8/10.

CC: “I am here for my annual exam and I also have these chancre-like wounds on my vagina for about a week. ”

HPI:

JC is a 20- year-old female G0P0AB0 who presents to the clinic today for annual well woman exam.  She states she also have lesions on her vagina. The patient appears to be in no distress. She is unaware of any exposure to STDs. Patient denies any fever, nausea, vomiting, abdominal pain, cramping, vaginal bleeding, vaginal discharge, diarrhea, constipation, change in stool, or hematuria. She rates pain on exam as 8/10.

Patient provided the HPI as follows:

O – Onset of symptoms 1 wk

L- Vagina

D – 1 wk

C – chancre like lesions

A – any contact with vagina aggravate.

R – No movement or no touching alleviate the pain

T – antiviral medication (Valtrex 1g po BID for 10 days), warm bath, topical lidocaine

S – Rates symptoms 8/10.

Medications:

none

PMH

Allergies:  Denies drug, food, latex, or environmental allergies

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Family History

Mother: Age 48. None

Father: Age 50. Hypertension

Paternal GM: Deceased. Unknown

Paternal GF: Deceased, HTN

Social History

Education Level: High school.

Occupational history: Works in hospitality.

Current living situation: Lives at home with mother.

Substance use/abuse: Denies substance use/abuse.

ETOH: Admits to 5-6 drinks weekly.

Tobacco Use: Never smoked

Safety Status: She states home environment is safe and free from abuse.

ROS

General

Patient denies fatigue, fever, chills. Denies weight change and night sweats. Denies lack of appetite. 

Cardiovascular

 Denies chest pain, palpitations, PND, orthopnea, and edema.

Skin

 Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles.

Respiratory

 Denies cough, wheezing, hemoptysis, dyspnea, pneumonia or TB history.

Eyes

Patient denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma, peripheral visual changes, and dry eyes.
 

Gastrointestinal

Patient denies N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools.

Ears

Denies ear pain, hearing loss, ringing in ears, discharge.

Genitourinary/Gynecological

Denies any urgency, frequency, chan