CASE STUDY:
History of Present Illness (HPI): Randi, a 22-year-old female, presents to the clinic with c/o of a 3-day
history of thick white vaginal discharge, intense vaginal itching, and dysuria. She reports she is sexually
active with 1 partner. No history of STI’s. She had a recent sinus infection and was on amoxicillin x 10
days.
Prior medical history: None.
Prior surgical history: None.
Current medications: Mirena IUD – inserted last year. Allergies: Sulfa
Social history: College student. Lives with mother. Denies smoking or recreational drugs. Vapes daily.
Family history: Mother alive and well. Father alive and well. Sister – diabetes: uses insulin pump
OB- GYN History: Menarche age 13, cycle length 5 days – frequency every 28 days. No history of
sexually transmitted infections (STIs). Never had a pap smear.
Review of Systems (ROS): As noted in HPI.
Physical Exam (PE)
VS: BP: 110/70, P: 109, RR: 17, T: 98.9, Weight: 132 lbs., Height 65 inches, BMI 22 kg/m2
• General: AAO x 3, pleasant.
• Gynecological: EXTERNAL EXAM: mild erythema, white clumpy discharge. SPECULUM/INTERNAL
EXAM: Cervix: normal appearance, no lesions, no bleeding, white discharge, no cervical
movement tenderness. UTERUS: normal size, shape, and consistency normal mobility,
nontender. ADNEXA: no masses or tenderness bilaterally.
RUBRIC:
Analyzes subjective and objective data and outlines applicable diagnostic tests related to case studies.
Identifies three differential diagnoses related to case studies.
Formulates a treatment plan related to case studies based on scientific rationale, evidence-based standards of care, and practice guidelines. Integrates ethical, psychological, physical, financial, and social determinants of health in the plan.
* Please use attached template
Important - Read this before proceeding
These instructions reflect a task our writers previously completed for another student. Should you require assistance with the same assignment, please submit your homework details to our writers’ platform. This will ensure you receive an original paper, you can submit as your own. For further guidance, visit our ‘How It Works’ page.