Comprehensive: vaginal dryness, dyspareunia,
dysmenorrhea
CM is a 27-year-old Caucasian female who is currently unemployed.
Reliable historian.
Chief complaints
Vaginal dryness with dyspareunia for the past six months, as well as
dysmenorrhea and poor flow with clotting. Also c/o headache during
the last five days of OCP’s and the first few days of menses. Taking tri
norinyl past year, she attributes the changes in her cycles to these
OCs. She states that she was switched to these pills about one year
ago for reasons that are not entirely clear to her. She cannot
remember the pills she was taking. However, she does remember that
the first OCs she took worked very well for her and she would like to
switch to them.
Past history
Childhood illnesses: Chicken pox.
Adult illnesses: None.
Accidents/injuries: none
Operations: T & A . Umbilical hernia. Wisdom teeth.
OB-GYN: GoPo, LMP May 9th. Bad Pap requiring biopsy 5 years ago.
Two since then were normal.
Hospitalizations: None.
Psychiatric illness: None.
Current health status
Allergies: None.
Immunizations: Current.
Screening tests: Pap 1 year ago. Dentist 1 year ago. Vision 1½ years
ago.
Environmental hazards: None.
Exercise: Bike. Walks.
Sleep patterns: 8-10 hours.
Diet: Adequate in protein and carbs.
Current medications: None except OCs
Occasional Advil for headaches and menstrual cramps.
Tobacco: None.
Alcohol/Illicit drugs: Occasional wine.
Family history
Mother: healthy
Father: hx of increased BP tx with loss of weight.
Maternal Grandmother: Stroke, mid-70s.
Maternal Grandfather: Hypertension, 82.
Paternal Grandmother: Hypertension, 78.
Paternal Grandfather: Deceased, heart problems, stroke in 80s.
Siblings: Older sister, 26, had some problem paps.
PSYCHOSOCIAL history
Lives with female roommate. Unemployed but currently contracting
with web company to do graphic art work. Degree in Art. Has
significant steady BF.
Review of systems
General: Usual weight. Denies fatigue, fever.
Skin: Denies rashes, lumps, sores, itching, dryness, color change,
change in hair or nails.
Head: See CC.
Eyes: Wears glasses and contact lenses. Denies pain, redness,
excessive tearing, double vision, glaucoma, cataracts.
Ears: Denies hearing difficulty, tinnitus, vertigo, earaches, infection,
discharge. See CC.
Nose and sinuses: Denies frequent colds. C/O occasional nasal
stuffiness related to allergies. Denies nosebleeds.
Mouth and throat: Denies bleeding gums, sore tongue, frequent sore
throats, hoarseness.
Neck: Denies lumps, goiter, pain, stiffness.
Breasts: Denies lumps, pain, discharge. Does BSE.
Respiratory: Denies cough, sputum, hemoptysis, bronchitis,
emphysema, pneumonia, TB, pleurisy. See CC.
Cardiac: Denies heart trouble, high blood pressure, rheumatic fever,
heart murmurs, chest pain or discomfort, palpitations, orthopnea,
PND, edema, EKG, other heart tests.
Gastrointestinal: Denies trouble swallowing, heartburn, appetite,
nausea, vomiting, indigestion, increased bowel movements,
constipation, change in bowel habits, rectal bleeding, hemorrhoids,
abdominal pain, excessive belching or passing of gas, jaundice,
hepatitis.
Urinary: Denies frequency of urination, polyuria, nocturia, burning,
pain, hematuria, urgency, hesitancy, incontinence, stones.
Genital: Menses regular, every 26-28 days on OCs.
Peripheral vascular: Denies leg cramps, varicose veins, clots.
Musculoskeletal: Denies joint pains, arthritis, gout, backache, redness,
pain, tenderness, stiffness, weakness, limited motion.
Neurologic: Denies fainting, blackouts, seizures, weakness, paralysis,
numbness, tingling tremors, or other involuntary movements.
Hematologic: Denies easy bruising, bleeding, past transfusions.
Endocrine: Denies thyroid problems, heat or cold intolerance,
excessive sweating, diabetes, excessive thirst, hunger, polyuria.
Psychiatric: Denies nervousness, tension, depression, memory loss.
Physical exam
Walks and moves easily and responds quickly and appropriately to
questions. Affect is pleasant with no evidence of anxiety of distress.
Pulse: 82.
Resp: 12.
BP: 120/86.
Height: 5’6”.
Weight: 157 lbs.
Labs: UA neg, HGB 12.4.
Skin: Color good, no lesions.
Head: Hair of average texture. Scalp and skull normal.
Eyes: Conjunctiva pink, sclera clear, PERRLA. Disc margins sharp. No
crossing changes, hemorrhages or exudates.
Ears: Canals clear and drums negative. Acuity good (to whispered
voice).
Nose: Mucosa pink, no sinus tenderness.
Mouth: Mucosa pink. Teeth in good repair. Tongue midline, tonsils
absent, pharynx pink.
Neck: Trachea midline. Thyroid not palpable.
Lymph nodes: No adenopathy in neck, axillary, epitrochlear or inguinal
areas.
Thorax and lungs: Thorax symmetrical, good expansion. Lung fields
resonant. Vesicular breath sounds throughout. No adventitious
sounds.
Peripheral vascular: All pulses strong and regular, no bruits. Normal
JVP. Extremities warm, without pallor, cyanosis, edema. No
varicosities or calf tenderness. Homan’s negative.
Cardiac: Apical impulse at 5th ICS. No heaves, lifts or thrills. S1 – S2
normal, no S3 or S4. No murmurs.
Breasts: No masses. Nipples without discharge.
Abdomen: BS normal, no masses or tenderness. No
hepatosplenomegaly. No CVA tenderness.
Genitalia: External – no lesions or discharge. Vaginal walls pink, nl
mucous. Cervix pink, nulliparous os. Uterus anteverted, normal size,
shape and configuration. No tenderness. Adnexa negative, ovaries
not palpable, non-tender.
Rectum: Not indicated.
Musculoskeletal: ROM normal. No joint deformities.
Neurologic: Alert, oriented x 3, CN intact II-XII, coordinated
movements and gait, negative Rhomberg. Cerebellar, sensory and
motor testing intact bilaterally for both upper and lower extremities.
DTRs intact and bilaterally equal.