SOLVED

History of Present Illness (HPI): Cindy is a 25-year-old Hispanic G1P0010 who presents to the office for annual gynecologic exam. Her LMP was 1 week ago, and she does not use contraception. The patient has no current complaints and denies abnormal uterine bleeding. She has never had cervical cancer screening and is unsure if she received the HPV vaccine. She reports 3 sexual partners in the last 6 months. Prior medical history: Chlamydia. Prior surgical history: None Current medications: None. Allergies: None GYN History: Menarche age 13, cycle length- 7 days- frequency every 28 days- 4-5 tampons per day. Positive history of chlamydia 1 year ago. Never had cervical cancer screening. LMP: 1 week ago. Contraception history: None, does not use condoms. Social history: Lives with a roommate. Works as a bartender. ETOH 3-4 vodka drinks 2 nights/week. Denies recreational drug use, never smoker. Family history: Unremarkable. Review of Systems (ROS): Negative. Physical Exam (PE) VS: BP: 110/70, P: 90, RR: 18, T: 98.4, Weight: 122 lbs, Height 5’6″., BMI 19.7 External: Appropriate hair distribution, No lesions, Small, painless lump palpated at left vaginal opening. Mild swelling noted. Speculum exam: Scant yellow vaginal discharge, no lesions, no cervical motion tenderness