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Follow-up: Will call patient with test results if abnormal. Otherwise, schedule annual Pap for next year.ICD 10: N94.6; Z30.09S: Follow up for severe menstrual cramps. LMP 12/15/17; occurs every 28-30 days. Days of flow: 3-5. Has missed one day of school every time she has a period. First menses age 13. Takes OCT Ibuprofen with no relief. Uses heat pad, helps a little with abdominal discomfort. Denies other symptoms such as vaginal discharge, dysuria, fever, or abdominal pain at times other than menstruation. Admits that she is sexual active with two life partners. Last sexual encounter was about a month or so ago. Uses condoms but not all the time. Has not had a pelvic exam not has been tested for STD, since her mother does not know that she has been sexually active and wouldnot like her mother to find out. Interested in birth control. O: Vitals: Temp: 98.7, HR: 88, RR: 18, BP: 110/68; H: 5' 4, W: 113, BMI: 19.4; External: Tanner5 pubic hair, normal genital development, no lesion. Internal: cervix- nulliparious, os closed, pink with no lesions. Scant clear mucoid discharge. Bimanual: anteverted uterus, normal size with no masses; adnexa- normal, non-tender.A: 16-year-old female Caucasian female, sexually active, with marked dysmenorrhea, in need of contraception. Parent not aware of sexual activity and patient prefers to keep it confidential today. Introduced oral contraceptive pills to patient and mother as a treatment for severe dysmenorrhea. Both mother and patient agreed to a 2-6 month trial of oral contraception along with high dose Ibuprofen. Differential Diagnosis: Endometriosis & PIDP: Labs: Denied STD or pregnancy testing right now due to mother being present.Medication: Ortho-Cyclen 28 day. Dis: 1 pack. Sig: 1 tab po qd. Refill: 2 and Ibuprofen 600 mg Dis: 30. Sig: 1 TAB PO TID for dysmenorrhea. Refill: 3.Education: Educated on contraception usage. Informed contest signed. Encouraged condom use when patient’s mother was not present in room. Follow-up: 3 months
ICD 10: N76.0S: c/c “I have very bad smelling discharge from my vagina.” Patient stated that the discharge is thick white and has been ongoing for one week, heavier in the morning. Has not tried anything form of treatment thus far. Reports one regular sex partner (for a period of one year) and 7 lifetime partners. States does not always use condoms, but knows the importance of using them. LMP: 12/22/17. Last pap: Unknown. G2T1P1A0L1; Twins at 21 weeks via C-section due to complications with pregnancy. Denies any other symptoms pelvic cramping, dysuria, unusual vaginal itching or burning, or n/v. O: Vitals: Temp: 99.1, BP: 128/64, HR: 81, RR: 19, W: 162, H: 5’10, BMI: 23.2. PELVIC: ext. genitalia + vaginal walls pink, pubic hair scant and shaven, cervix intact, closed os, thick white foul smelling discharge noted in vaginal canal, lower pelvic tenderness on bimanual exam, uterussmooth and within normal limits, ovaries not palpable.