STI Investigation: A Case Study

Patient Overview

Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full-time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / EtOH only on weekends, 6-8 hard liquor/ daily, and marijuana smoking. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has some cramping during her menses for which she takes otc Pamplin. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies.

Susan’s vital signs are taken and were temperature 97.8, pulse 68, BP 112/64, height 5’6” and weight 118 lbs. (which was the same as last year). BMI 19.04

HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened.

Lung:clear to auscultation

CV: regular sinus rhythms without murmur or gallop

Abd: soft, non-tender, liver normal,

Breasts:fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.

VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted

Cervix: friable, some petechia no cervical motion tenderness.

Uterus: mid mobile, non-tender

Adnexa: without masses or tenderness

Perineum:wnl

Rectum:wnl

Extremities: full rom, skin clear, no edema, reflexes 1+.