Vaginitis

HISTORY:

Vaginal ‍itchingburningdischarge for ‍ ‍hoursdays

‍itching

‍discharge, ‍clear, ‍thin

‍fishy smell

‍vaginal discomfort

‍burning

‍painful urination

‍painful intercourse

‍abnormal bleeding

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, anus ‍normal

Pelvic:

- External genitalia: ‍normal, ‍inguinal lymphadenopathy

- Vagina: ‍normal, discharge ‍normal, ‍malodorous

- Cervix: ‍normal

- Uterus: ‍normal, ‍no cervical motion tenderness

- Adnexa: -R ‍normal, -L ‍normal

- Tests performed: ‍Pap test, ‍HPV DNA, ‍vaginal culture, ‍chlamydia/gonorrhea, vaginal pH ‍< 4.5> 4.5, whiff test with KOH ‍negative

- Performed with chaperone



ASSESSMENT:

‍Yeast infection ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Vaginal culture

- Wet mount microscopy

- STI screening

- Blood work: ‍HIV, ‍Syphilis, ‍Hepatitis B, ‍Hepatitis C, ‍Glucose, ‍HbA1C

- ‍Vaginal antifungals

- ‍Fluconazole

- Avoidance of irritants (soaps, bubble baths, douches, feminine sprays)

- Referral to gynecologist

- Follow-up in ‍ ‍daysweeks

- Return if symptoms do not improve or if develops fever or abdominal pai