PATIENT CASE PRESENTATION

 

Ms. K.C.. is a 25 y.o. white female, who presents to the emergency department with complaints of dysuria, clear vaginal discharge and vaginal itching. She states she started to notice these symptoms a couple days ago, so she decided to come get checked out. She endorses having unprotected sex with multiple sexual partners in the last 2 weeks as well as having a history of drug abuse.

Past Medical History:

  • Appendectomy, age 18 y.o.
  • Generalized Anxiety Disorder, diagnosed age 20 y.o. 
  • Gastroesophageal Reflex Disorder, diagnosed age 24 y.o. 

 

Pertinent Family History:

  • Mother has a history of Pelvic Inflammatory Disease and recent Hysterectomy at age 57
  • Father has a history of Hypertension and Hyperlipidemia at age 58
  • Brother is alive and well with no pertinent medical history at age 21
  • Sister died of cervical cancer at age 27

 

Pertinent Social History: 

  • Heavy alcohol use: patient reports drinking 4-5 days a week, consuming 20 drinks/week
  • Current everyday smoker: 1 pack/day for 7 years 
  • History of multiple sexual partners, uses oral contraceptives for protection, denies use of condoms
  • Drug abuse, cocaine use occasionally and marijuana daily