CC: “Vaginal itching x 1 month”
HPI:
A 24 y/o female G0 LMP 03/06/23 presents to OBGYN clinic complaining of vaginal irritation with discharge which began 1 month ago. Patient says it is whiteish discharge that is associated with a strong odor. She also admits to increased urinary frequency and dysuria which also began around the same time. Patient claims it has always been there and she has not tried anything to alleviate it. Pt claims she is currently sexually active with one partner for the past 2 years who is currently asymptomatic. Denies any previous partners other than this one, denies any history of STIs, and denies use of any antibiotics recently. Pt says this has never occurred before. Pt denies fever, chills, vaginal bleeding, lesions, back pain, abdominal pain, or N/V.
OBGYN history: No prior gyn exam. Sexually active. Denies hx of STIs.
Past Medical History: No significant past medical history
Past Surgical History: No significant past surgical history
Home Medications: Pt denies taking any medications
Allergies: NKDA
Family History: Not obtained.
Social History: Pt denies ever smoking.
Immunizations: COVID vaccine and flu vaccine status unknown.
ROS:
General: denies fever, headache, weakness, recent weight loss
Chest: denies breast mass, nipple discharge, chest tenderness
Cardiac: denies CP, SOB, palpitations
Respiratory: denies SOB, cough
GI: Denies nausea, vomiting, diarrhea, constipation, abdominal pain
GU: Reports whiteish color vaginal discharge with a strong odor. Reports increased frequency in urination, dysuria, and pruritus. Denies hematuria.
Vital Signs:
BP: 124/76 Right Arm, seated
RR: 18
Pulse: 82 BPM
Temp: 97.8 F oral
Physical:
General: afebrile, appears stated age, neatly groomed, well nourished, A & O x 3, and in no acute distress.
Chest: nontender to palpation
Breast: Symmetric, no lesions, no masses, no axillary lymphadenopathy, no nipple discharge, and no dimpling.
Abdomen: soft non-distended abdomen, nontender to palpation, no striae or pulsations. Bowel sounds symmetric in all 4 quadrants, no CVA tenderness.
Pelvic: External genitalia without masses or scarring.
Vagina: Whiteish color discharge with slight odor.
Cervix: pink, no lesions, not friable.
Uterus: small, mobile, nontender.
Adnexa: nontender b/l and no masses felt on palpation
Assessment:
24 y/o G0 LMP 4/19/23 w/ no PMHx presents to clinic with complain of vaginal irritation w/ increased urinary frequency, dysuria, and discharge for past month. Exam significant for white vaginal discharge along with slight odor and pruritus concerning for bacterial vaginosis.
Differential Diagnosis:
- Bacterial Vaginosis
- Trichomoniasis
- UTI
- STI (Gonorrhea/Chlamydia)
Plan:
Vaginitis panel w/ vaginal swab. Begin Metronidazole (500 mg BID x 7 days)
UTI: R/o with urinalysis w/ reflex urine culture
Syphilis: Syphilis screen w/ Treponema Pallidum Ab
Chlamydia/Gonorrhea – NAAT test
HPV – pap smear PCR and cytology
