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 Pamprin. 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+.
· Neurological: CN II-12 grossly intact.
review a case study scenario to obtain information related to a comprehensive well-woman eval and determine differential diagnoses, diagnostics, and develop treatment and management plans.
Sample Solution
Impression of Susan Lang’s physical exam findings is consistent with postcoital bleeding, mild cervical inflammation/infection, fibrocystic changes in breasts bilaterally, bilateral nipple piercings and clitoral piercing. Further testing may be needed to evaluate for underlying cause of postcoital bleeding such as Pap smear, endocervical culture and gonorrhea/chlamydia tests. Patient should also be counseled on cessation of smoking and substance use as well as safer sexual behaviors to reduce risk for Sexually Transmitted Infections (STIs).
Sample Solution
Impression of Susan Lang’s physical exam findings is consistent with postcoital bleeding, mild cervical inflammation/infection, fibrocystic changes in breasts bilaterally, bilateral nipple piercings and clitoral piercing. Further testing may be needed to evaluate for underlying cause of postcoital bleeding such as Pap smear, endocervical culture and gonorrhea/chlamydia tests. Patient should also be counseled on cessation of smoking and substance use as well as safer sexual behaviors to reduce risk for Sexually Transmitted Infections (STIs).