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Ihuman Case Study Week 7 Vagina
Itching And Foul Odor Discharge
Patient Identification:
Initials: L.E Age:28 years Sex: Female Race: Caucasian
SUBJECTIVE DATA
Chief Complain (CC): Vagina Itching and foul odor discharge
History of Present Illness (HPI): The patient is 28 years old Caucasian female who presents
with vaginal itching with foul odor discharge. The symptoms started a week ago and became
severe yesterday. The discharge is white. She stated the symptoms occur intermittently
throughout the day. The symptoms get worse with intercourse, and she has tried douching with
no relief. She denies the use of condoms but takes birth control pills. She denies vagina bleeding
or abdominal pain, she sometimes experiences burning and pain on urination with the symptoms
and is currently using Desitin cream with no relief. She has not had these symptoms in the past
and rates the symptoms as 3/10.
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PAST MEDICAL HISTORY
Current Medication: One tab of Tri Sprintec birth control pill daily. Tylenol 650mg every 6
hours as needed for headache.
Allergies: No Known drug or food allergy
She denies major illness or trauma
She denies recent hospitalizations but had 1 c -section in 2015, which was planned and is up to
date on her immunizations.
Family History: Mother has hypertension, no significant history of the father, has no history of
both grandparents who died when she was still a child.
Social History: L. E works at a restaurant as a chef. She is married with one child and loves
spending time with her family. Denies smoking and alcohol use denies the use of illicit drugs.
REVIEW OF SYSTEM:
General: No weight loss, fever, weakness or chills
Cardiovascular: denies chest pain or pressure when coughing, no edema, or palpitations.
Respiratory: denies shortness of breath or cough
Gastrointestinal: No abdominal pain, denies anorexia or vomiting, denies constipation, and
diarrhea.
Ihuman Case Study Week 7 Vagina
Itching And Foul Odor Discharge
Patient Identification:
Initials: L.E Age:28 years Sex: Female Race: Caucasian
SUBJECTIVE DATA
Chief Complain (CC): Vagina Itching and foul odor discharge
History of Present Illness (HPI): The patient is 28 years old Caucasian female who presents
with vaginal itching with foul odor discharge. The symptoms started a week ago and became
severe yesterday. The discharge is white. She stated the symptoms occur intermittently
throughout the day. The symptoms get worse with intercourse, and she has tried douching with
no relief. She denies the use of condoms but takes birth control pills. She denies vagina bleeding
or abdominal pain, she sometimes experiences burning and pain on urination with the symptoms
and is currently using Desitin cream with no relief. She has not had these symptoms in the past
and rates the symptoms as 3/10.
, 2
PAST MEDICAL HISTORY
Current Medication: One tab of Tri Sprintec birth control pill daily. Tylenol 650mg every 6
hours as needed for headache.
Allergies: No Known drug or food allergy
She denies major illness or trauma
She denies recent hospitalizations but had 1 c -section in 2015, which was planned and is up to
date on her immunizations.
Family History: Mother has hypertension, no significant history of the father, has no history of
both grandparents who died when she was still a child.
Social History: L. E works at a restaurant as a chef. She is married with one child and loves
spending time with her family. Denies smoking and alcohol use denies the use of illicit drugs.
REVIEW OF SYSTEM:
General: No weight loss, fever, weakness or chills
Cardiovascular: denies chest pain or pressure when coughing, no edema, or palpitations.
Respiratory: denies shortness of breath or cough
Gastrointestinal: No abdominal pain, denies anorexia or vomiting, denies constipation, and
diarrhea.
