HPI:
Ms. Landry complains of a three-month history of intermittent
vaginal bleeding throughout her menstrual cycle that is increased during
menstrual periods. During
this same period, she notes lower abdominal cramping and pain with deep
pelvic thrusts during intercourse. She
admits to having occasional post-coital bleeding.
She denies any abnormal vaginal discharges, nausea, appetite
changes, or breast tenderness. She
also denies increased frequency, urgency, or changes in bowel habits.
She denies weight loss, excessive exercise, or increased stress.
Her
age at menarche was 12 years and has had mostly regular menstrual cycles,
approximately every fourth week, until approximately six months ago.
Her menstrual periods typically last four days but recently they
have persisted for as long as two weeks.
She notes mild to moderate
dysmenorrhea although not every cycle.
She has had no known pregnancies but has used various methods of
contraception in the past.
She
has had two episodes of vaginal Candidiasis, the last occurring
approximately four years ago. She
denied any history of gonorrhea, chlmydia, or any other sexually
transmitted disease. She
states that she has had about ten sexual partners over the years, but none
she would consider high risk. Her
last Pap smear was four years ago and was normal.
She has used oral contraceptives extensively in the past but has
not used them for the past two years because she has not had a steady
partner. She has had two
partners in the past six months.
Past
Medical History: non-contributory
Past
Surgical History: none
Medications:
none
Allergies:
none known
Social
History: single, lives alone, works as a secretary at a local law firm,
smokes 1 pack of cigarettes per day for past twelve years, consumes 6-10
alcoholic drinks per week, no recreational drug use
father,
age 62, has Type II diabetes mellitus and coronary artery disease
mother,
age 57, had hysterectomy ten years ago due to uterine fibroids and
hypothyroidism controlled on Synthroid
-brother, age 32, has asthma
