Use the attached Template to complete the below case study. Support your work with 6 APA reference.
Case Study 1: Debbie
History of Present Illness (HPI): Debbie is a 19–year–old female G1P0010. She presents to your office as a
new patient for GYN visit. Her chief complaint is mild lower abdominal pain and a copious amount of
vaginal discharge that started a little over 1 week ago. She is sexually active and reports having four male
partners in the last six months.
Prior medical history: Depression, HSV–2. Prior surgical history: Surgical termination of pregnancy 1
year ago
Current medications: Lo loestrin Fe. Allergies: None
OB– GYN History: Surgical TOP x 1. Menarche age 9, cycle length– 7 days– frequency every 28 days– 3 –4
tampons per day. Hx of HSV–2. Never had pap smear.
LMP: 2 weeks ago – normal. Contraception history: OCP since TOP 1 year ago.
Social history: Lives parents. Denies ETOH or recreational drug use, never smoker. Graduated high
school. Not in college. Works FT as a waitress.
Family history: Mother – depression. Father – unknown
Review of Systems (ROS): Negative except as noted in HPI.
Physical Exam (PE)
VS: BP: 112/80, P: 72, RR: 16, T: 98.4, Weight: 110 lbs., Height 54 in, BMI 18.9 kg/m2
• General: WDWN female in NAD
• Abd: Soft, NT/ND, no masses/HSM
• GU: No external lesions, no erythema. Mucopurulent endocervical exudate visible in the
endocervical canal, sample obtained – cervix is friable. Mild CMT, no uterine tenderness, no
adnexal tenderness, no masses.
