W.F Case of Vaginal and Burning

“I have vaginal itching and burning, earache, and sore throat”

W.F. is a 58 y/o white female with a history of vaginal itching and burning.  She was treated in October 2014 with Acyclovir for r/o genital herpes.  She was instructed to follow-up with primary physician but she did not due to “not being able to afford it”.  She states the vaginal irritation did not completely alleviate but was getting better for a while.  Patient states pain got better but now has been experiencing increased itching for the last four days.  States she has been using Aveeno lotion to soothe the itching and burning but it is no longer working.  Denies internal vaginal itching and irritation.  Also denies any associated symptoms.  Patient report ear pain x 2 weeks with notice of sore throat off and on since last night.  Describes throat as scratchy without cough.  She denies any use of OTC medication to treat sore throat or ear pain.

Allergies:  None

Medication Intolerances: None

Chronic Illnesses/Major traumas: History of cocaine drug use.

Hospitalizations/Surgeries: Denies any hospitalizations outside of vaginal birth 31 years ago. Tonsillectomy as a child

W.F.’s parents are deceased. Her mother died in 2006 from heart disease and she is unsure of the reason for father’s death in 2010.  Maternal grandmother is deceased from massive heart attack and unsure of maternal grandfather and paternal grandparents cause of death.   She has one living brother in Alabama that may have diabetes.  W.F. has one daughter that lives three hours away with no health problems.

Patient is single and never was in a relationship with the father of her child.  She is not in a relationship at this time.  She is a GED graduate that now works as a housekeeper in environmental services.  Patient admits to cocaine drug use but has been clean through self-detox for the last 15 years.  She admits to pack/day cigarette smoking and admits to social alcohol drinking less than three times per month.  Attends church on occasions.  States she gets along well with co-workers but is mainly friends with two of her neighbors.  No immediate family in the area.  She participates in employer health plan.

W.F Case of Vaginal and Burning

Denies weight change.  “I work 24-30 hours per week, I am always tired”.  Denies fever or chills

Denies chest pain, palpitations, or edema

Vaginal rash, none on other body parts

Denies cough, wheezing, SOB

Denies visual changes; wears glasses. Dark circles under eyes from vaginal itching awakening

Denies abdominal pain, n/v/d, or bowel changes. Denies black stools

Denies hearing loss or tinnitus; outer ear pain x 2 weeks; denies trauma but sore on left ear

W.F Case of Vaginal and Burning

Denies dysuria, hematuria, urgency or frequency. Admits to vaginal itching and burning x 4 days. Denies sexual activity. Denies vaginal odor or excessive discharge

No Sinus problems, nose bleeds or discharge. Scratchy throat. Denies dysphagia or hoarseness

Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

Small knot behind ear