Chief Complaint: “Need help getting pregnant”
History of Present Illness:
28 y/o G2P1011 presents for her routine GYN visit in clinic expressing a desire to conceive. She states she has been with a new partner for 12 months and has been actively trying for the past 6 months. She states she had her first child at 19(vaginal delivery)with her ex husband. She has regular menstrual cycles every 28-30 days and denies any history of sexually transmitted infections, pelvic inflammatory disease, or gynecological surgeries.Her partner is a 30-year-old male with no known health issues or history of infertility. Neither she nor her partner have undergone any fertility evaluations or testing. Patient states that she is currently taking birth control pills stating that she was told by another doctor that this would improve her chances of getting pregnant. She states she has been taking them for 5 years now.
Patient today also complains of vaginal irritation for 3 weeks. Patient states that irritation is associated with a funny smell and states she has seen white discharge come out as well. She denies any alleviating or aggravating factors and states she has taken nothing to alleviate the itching. Patient denies any dysuria, polyuria or any other symptoms currently. Patient states she is concerned if this is having an affect on her pregnancy.
MEDICAL HISTORY:
Medications:
Norgestimate-ethinyl estradiol(ORTHO TRI-cyclen LO) 0.18/0.215/0.25mg-25 mg mcg tablet
Medical History:
No significant past medical history
Surgical History:
Denies any surgical history
Allergies:
No known drug allergies
No known food allergies
No known environmental allergies
Family History:
Mother: alive & well, hx of HTN and DM
Father: alive & well, no significant PMHx
No known family hx of cancer or cardiac disease
1 son: alive and well
Social History:
Nonsmoker
Denies alcohol use. Denies illicit drug use
Occupation: Not working
Caffeine: Reports occasional caffeine use
Marital history: Divorced, currently in relationship
Home situation:Living in apartment with boyfriend and son
Diet: Patient reports reports poor diet, consisting of fast food
Exercise: Denies any physical activity
GYN History:
Last PAP done 03/23, cytology negative
Sexually active with 1 male partner
Denies history of STIs
ROS:
General: Denies recent weight loss or gain, fever, or recent illness.
Skin:Reports mild vaginal pruritus. Denies vaginal skin discolorations, pigmentations or lesions.
Breast: Denies tenderness, nipple discharge, dermatological changes, or vascular changes.
Chest: Denies history of HTN, chest pain, syncope, palpitations, hx of known heart murmur.
Pulmonary system: Denies dyspnea, cough, wheezing, and dyspnea on exertion.
Gastrointestinal system: Has regular bowel movements daily. Denies constipation, diarrhea, bloody stool, nausea, vomiting, and hemorrhoids.
Genitourinary system:Reports white vaginal discharge that smells. Denies urinary frequency or urgency, dysuria, or flank pain.
Physical Exam:
General: Obese 28 y/o female in no acute distress, alert & oriented x 3.
Vitals:
BP: 117/65
Pulse: 96
Temp: 98.0
Wt: 270lb
Ht: 5’ 7”
BMI: 42.3kg/m2
Skin: Warm and moist throughout. No erythema.
Breast: Symmetric, no lesions, no masses, no axillary lymphadenopathy, no nipple discharge, and no dimpling.
Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Lungs: Clear to auscultation bilaterally, no adventitious sounds noted. Chest expansion and diaphragmatic excursion symmetrical.
Abdomen: Abdomen symmetric. Vertical scar noted to lower abdomen. Bowel sounds normoactive in all four quadrants.
Female Genitalia: External genitalia without erythema or lesions.Mildly erythematous, Thick curdy white discharge in vaginal canal with distinct odor.Cervix pink and without lesions. No cervical motion tenderness. Uterus anterior, non-tender and not enlarged. No adnexal tenderness or masses noted.
DDx:
Candida Vaginitis
Bacterial Vaginosis
STI(Chlamydia/Gonorrhea)
Assessment:
28 y/o G2P1011 comes in today due to concerns about having difficulty conceiving. Patient to discontinue taking birth control pills if she is trying to get pregnant as she was misinformed on its use.
Patient complaint of vaginal irritation for 3 weeks, with exam significant for white discharge and strong odor from vaginal canal is consistent for Candida vaginitis.
Plan:
#Conceive
- Patient was educated to discontinue birth control pills to improve chances of getting pregnant.
- Discuss lifestyle modifications and continued healthy practices to optimize fertility
#Yeast Vaginitis
Vaginitis panel(Candida, Trichomonas, Gardnerella)
Chlamydia/ G.C PCR(Swab):Endocervical
Syphilis Screen
HIV AG/AB Screen
Start Clotrimazole 2 % vaginal cream nightly for 3 days
