SUBJECTIVE
This is a 19-year-old single white female college student who is seen with reference to vulvar pain and urinary burning of 2 to
2-1/2 days’ duration. She denies any prior GU infections. She is sexually active with multiple partners but seldom uses condoms. She is on oral contraceptive. Gravida 0. LMP about
2 weeks ago. She noted onset of vulvar itching and burning on Monday afternoon associated with pain on voiding. This has become steadily worse to the point where she can now hardly void at all. She thinks she may have had some fever last night. She has noted slight increase in vaginal discharge. She has had no urinary frequency, no blood in the urine, no flank pain, chills, nausea, but she has been anorexic. Some headaches in the past
24 hours. She is on no medicine except Demulen, and Advil for her pain, which is not helping.
2-1/2 days’ duration. She denies any prior GU infections. She is sexually active with multiple partners but seldom uses condoms. She is on oral contraceptive. Gravida 0. LMP about
2 weeks ago. She noted onset of vulvar itching and burning on Monday afternoon associated with pain on voiding. This has become steadily worse to the point where she can now hardly void at all. She thinks she may have had some fever last night. She has noted slight increase in vaginal discharge. She has had no urinary frequency, no blood in the urine, no flank pain, chills, nausea, but she has been anorexic. Some headaches in the past
24 hours. She is on no medicine except Demulen, and Advil for her pain, which is not helping.
OBJECTIVE
This is a very distraught young lady. She is tearful and obviously in considerable physical and mental distress. Temperature is 99.8, pulse 100, blood pressure 132/78. Her skin is pale, warm, and dry. Examination limited to genitourinary system reveals a cluster of shallow, discrete ulcers on the left labium minus, and these are surrounded by an angry erythema, and their bases are covered with a shaggy, grayish exudate. There is generalized edema and erythema of the vulva. There is a moderate amount of excessive secretion at the introitus, nonspecific in character. Several tender lymph nodes are palpable in both groins. Bimanual examination is deferred because of the severity of the patient’s symptoms at this time. However, abdominal examination shows no bladder distention. Scrapings are taken from 2 ulcers with a #15 blade and smeared and stained immediately by the Tzanck technique with toluidine O. Examination of the smear shows giant cell formation typical of viral infection.
ASSESSMENT
Herpes simplex virus infection, left labium minus, probably type 2, probably primary.
PLAN
1. The diagnosis and its implication were fully discussed with the patient, in association with a female counselor, and she was given printed literature to take with her. She was advised that she is presently infectious and must abstain from sexual contact until she is well. She was advised that recurrences are not invariable and that she may not have any. She was advised that should she have a recurrence, she will again be infectious, but that recurrences are typically milder than the primary infection. She was advised that she has an increased risk of cervical dysplasia and neoplasia and needs annual Pap smears from here on out. She was advised that should she have a recurrence near term of pregnancy, she would need cesarean section. She was advised to inform any prospective marriage partner of her diagnosis. Though obviously upset, she verbalized comprehension of these instructions. She was given some further counseling by the counselor after I left the room and will be seen in followup by them as well as by me on a p.r.n. basis.
2. Zovirax 200 mg p.o. q.4h. for 5 doses a day x10 days.
3. Tylenol No. 3, 1 or 2 tablets q.4-6h. p.r.n. for pain.
4. Zinc oxide ointment to be applied to the lesions as often as needed to prevent urinary burning, protecting the finger with a finger cot or condom.
5. She is to watch bladder function and to call the clinic day or night if she cannot void.
6. She will be scheduled back here in 1 to 2 weeks for pelvic examination, Pap smear, and STD screen, including Thayer-Martin, Chlamydia slide test, and a wet mount for Candida, Gardnerella, and Trichomonas.
FOOTNOTE
Lines 7 (Page 1) to end. Alternatively, this report can be typed in regular SOAP format:
S:
O:
A:
P:
Line 20 (Page 1). A comma was placed after Demulen (a contraceptive pill) for clarity. (Advil for pain was not helping: Demulen is not a pain medication.)
Line 26 (Page 1). The slang term temp was expanded to temperature, and BP was changed to blood pressure.
Line 8 (Page 2). Translate C-section as cesarean section.
Expand the abbreviations in the report.
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