CASE STUDY: LEGAL ANALYSIS

A 15-year old female presents to your clinic with complaints of vaginal discharge. She reports a

3-month history of green vaginal discharge and a recent onset of lower abdominal pain. She

reports her last menstrual period was 7-weeks ago. She admits she has been sexually active with

3 male partners in the past 4 months. She has never used any form of protection or

contraceptive. She reports she took a home pregnancy test 1 week ago and that it was positive.

Past Health History: No history of health problems.

Surgical History: Appendectomy 7 years old.

Family History: Father with Hypertension. Mother and siblings healthy.

Social History: Lives with parents and one older female sibling in a single-dwelling home. She

is a 10th grade student in local high school. She describes herself as a “C-student” and does not

participate in any extracurricular school activities or athletics. She reports experimenting with

alcohol and cigarettes when she was in junior high school but that “both made her so sick” that

she did not continue to use. Denies illicit drug use in the past or present. She reports feeling safe

in her home. She’s had an 18-year old boyfriend for the past two months and her parents and she

thinks her parents are unaware of her relationship with him. She denies history of emotional,

sexual, and physical abuse. She reports she feels safe in her home and when she is with her

boyfriend.

Physical exam reveals an afebrile, well-appearing female. Pelvic exam reveals a friable cervix

with green discharge from the cervix. There is no cervical motion or adnexal tenderness.

Diagnostics: Urine HCG positive. STD testing is positive for chlamydia and negative for N.

gonorrhea; rapid plasma regain (RPR) is nonreactive.