Foul Smelling Discharge
HPI
DF is a 25-year-old Hispanic female presenting to the clinic for foul smelling vaginal discharge that started three days ago. DF describes the vaginal
discharge has a copious amount of yellow greenish discharge that has a pungent odor. DF describes the smell as fishy and denies any vaginal or pelvic pain
associated with the discharge. Furthermore, one day ago DF did use a vaginal boric acid suppository to help with her symptoms. She explains that the vaginal
suppository worsened her symptoms and caused some irritation to her peri area. She denies irregular bleeding, painful coitus, and pelvic/abdominal pain. DF is
sexually active and has had four new partners within the last six months. She reports that she occasionally uses condoms and does have a positive history for STDs
(reportedly gonorrhea). Her last sexual encounter was right after using the vaginal suppository, and she denied condom use.
ROS
General: denies fevers, chills, fatigue, weight gain
Dermatology: denies moles, rashes, pruritis
HEENT: denies headache, nasal congestion, earaches
Neck: denies painful swallowing, swelling,
Pulmonary System: denies cough, increased work of breathing, or breathlessness
Cardiovascular System (CVS): denies chest pressure, dizziness, irregular heartbeat
Breast: denies breast tenderness, breast discoloration, mass
Gastrointestinal (GI) System: denies constipation, abdominal pain, nausea and vomiting
Genitourinary (GU) System: denies polyuria, dysuria, incomplete emptying of bladder
Female Genitalia: reports copious amounts of yellowish green vaginal discharge, reports fishy vaginal odor, and vaginal irritation. LMP 1/2/23.
Musculoskeletal System: denies noisy joints, difficulty bending, and joint stiffness
Psychologic: denies suicidal ideation or feelings of wanting to harm others, anxiousness, sadness, and feeling overwhelmed
Assessment
Vitals: BP 136/ 78, RR 22, Temp 37 , HR 66, O2 97% RA, Weight 176 lb, Height 5ft 5nch, BMI 29.3 (overweight)
General: Alert and oriented, in no acute distress, well groomed, behavior appropriate
HEENT: Head is normocephalic. Scalp clean without dandruff. Ears: Ear canal patent. Tympanic membrane without peroration. Eyes: PERRLA, EOM intact.
20/20 vision in both eyes. No nystagmus. No conjunctival irritation. Nose: Mucosa is pink. No bleeding. Throat: Moist oral mucosa
Cardiovascular: S1 & S2 auscultated. No abnormal heart sounds. JVD is negative. Carotid, radial and pedal pulses +2 bilaterally. No extremity edema present.
Respiratory: Respirations are even and unlabored. Respiratory rate 18. No SOB. Chest expansion equal. Clear lung sounds in all lobes.
GI: Normoactive bowel sounds. No abdominal distention. Abdomen nontender to palpation.
GU: Bladder is not palpable. Right kidney palpable. Left kidney not palpable. CVA without tenderness.
Female Genitalia: vaginal cultures: Yellowish greenish discharge with potent fishy odor. Uterus not enlarged. Non tender uterus. Ovaries are not palpable. Cervix
with small petechiae.
Breast: breast size equal in size bilateral, no dimpling present, no mass palpated; breast is nontender and nonpainful
Musculoskeletal: : No gait unsteadiness. Active ROM in all joints. Spine is without deformity. No muscle weakness noted.
Integumentary: Skin is intact. Skin tone is even. No jaundice present. Skin turgor is normal. Skin is warm to touch. Normal nail bed, no clubbing
Neuro: A/O X 3. Speech is slowed and clear. Sensation is intact in all extremities. Tendon reflexes are +2 bilateral. Cranial nerves not tested.
Hematologic: No active bleeding. No bruising present. No petechiae.
Psych: Normal and coherent thought processes. No signs of mania. No signs of depression.
