Case description for C-Takes documenting:
Setting: Outpatient.
Specialty: OB/GYN. 
Note detail level (1-5): 2.
Level of abbreviation (Low/Medium/High): Medium.

HPI/CC: Mrs. X is a 33yo G1P1 with a LMP of Feb 5th and a known history of PCOS who presents to the clinic today with a CC of pelvic pain, spotting, and vaginal odor.
Patient had an Mirena IUD placed on the 6th of Feb. Since that time she has experienced cyclic suprapubic/vaginal pain that she associates with the IUD placement.
The pain has ranged from 6-10/10. Patient has been taking Norco prescribed for chronic back pain to help "deal" with the IUD related pain.Patient reports feeling dizzy
and lightheaded since the placement. Upon further questioning patient reports that her partner can "feel the strings poking him" during intercourse.
However, she claims she can not locate the IUD strings on self examination.

ROS: Patient denies n/v, f/ns, sob, and cp. She denies dysuria and reports normal bowel movements. 
PMHx: PCOS, otherwise not contributory.
SurgHx: Not contributory.
FamHx: Not contributory.
SocHx: Not contributory.
Meds: Gabapentin/Norco (chronic back pain).

Vits: BP 113/67, HR 59, T 98.4
PE: Reveals a fairly fit woman of stated age in mild distress. Normal labia. No discharge on speculum exam but some blood was noted in the vault along with a faint
unpleasant odor. 

Labs/Anc: KOH Wet prep revealed multiple hyphae per hpf. Gen probe pending. 

A/P: Mrs. X is a 33yo G1P1 in no acute distress. In clinic for IUD check. Found to have yeast infection incidentally on KOH wet prep. Will treat with diflucan. 

