History

CC:

“I have burning and itching” x2 months.

HPI:

Pt is a G2P2002 female, LMP 06/10/2024, who presents to the outpatient clinic today with complaints of vaginal itching and burning x2 months. Pt says she thinks this has to do with her use of Plan B. She used a Plan B 3 months ago and began to experience her symptoms 2 months ago. She says she had a similar experience one time before this when she used Plan B and then had vaginal itchiness. She says the symptoms come and go during the day and ranges between 5/10 and 8/10 in severity. Pt says she has tried to treat her symptoms with boric acid but has not achieved any relief. She says the burning sensation is worse when she urinates. Pt states that the last time she was sexually active with her long time boyfriend and father of her children was 3 months ago when she used the Plan B. No form of barrier contraception was used. She denies having sexual encounters with any new partners. Because she has not been sexually active with her partner since 3 months ago, before the onset of symptoms, she doesn’t know if the pain and itching is worse with intercourse.  

Pt denies abnormal vaginal discharge, urinary frequency, urinary urgency, polyuria, weight changes, fever, chills, use of new soaps/detergents, known medical history including DM and wearing tight or damp clothes for long periods of time.

Medical History:

• Denies

Medications:

• Denies

Surgical History:

• C section x2

Allergies:

• No known drug/food/environmental allergies

Ob/gyn History:

• C section x2
• Last pap 6/10/22- neg
• Denies history of STDs

Family History:

• Mother: Unknown
• Father: Unknown
• 2 children: alive and well
• No known family history of cancer or cardiac disease. Known family history of DM.

Social History:

• Smoking: Denies
• Alcohol: Drinks socially
• Illicit drug use: Denies past or current use
• Marital History: Boyfriend
• Language: Spanish
• Occupational History: Home attendant 
• Travel: No recent travel
• Home situation: Lives at home with partner/father of baby and 2 children
• Sleep: Endorses adequate sleep
• Exercise: Walks around the block daily
• Diet: Reports balanced diet of protein, fruits, vegetables and healthy carbs. 
• Caffeine: Denies caffeine use 

ROS:

• General: Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies epistaxis, nasal congestion, sore throat, head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, discharge, bleeding gums.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Breast: Denies lumps, nipple discharge, or pain.
• Pulmonary: Denies cough, hemoptysis, dyspnea, wheezing, cyanosis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary: Admits to dysuria. Denies urinary frequency, nocturia, urgency, flank pain, oliguria, incontinence, polyuria, vaginal discharge and malodorous urine.
• Menstrual/Obstetrical: G2P2002, LMP 06/10/2024; not currently sexually active 
• Musculoskeletal: Denies back pain, muscle pain, joint pain, arthritis and joint swelling.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric: Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional.

Physical

General:

• Well developed, overweight female in no apparent discomfort. Appears stated age of 42. Neatly groomed, alert and oriented x3.

Vital Signs: 

• BP: 115/70 mm Hg
• R: 18/min, regular rate and rhythm, unlabored
• P: 83 beats per minute, regular rate, rhythm and amplitude 
• T: 97.2 degrees F (temporal)
• Height: 66 inches Weight: 166 lbs BMI: 26.52

Lungs:

• Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac Exam:

• Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal Exam:

• Abdomen flat and symmetric with no scars, striae or pulsations noted. Nontender to palpation and tympanic throughout, no guarding or rebound noted. 

Pelvic Exam:

• Vulva: Normal female external genitalia without erythema or lesions. 
• Vagina: Pink mucosa without inflammation or erythema. White thick curd-like discharge.
• Cervix: Nulliparous, pink and without lesions. White thick curd-like discharge. No cervical motion tenderness. 
• Uterus: Anterior, midline, smooth, non-tender and not enlarged. 
• Adnexa: No tenderness or masses noted. No inguinal adenopathy.

Differential diagnosis:

• Vaginal candidiasis
  • This diagnosis typically causes vaginal itchiness and burning with thick, white discharge. This is exactly the symptoms that the pt is describing and was backed up by the findings on physical exam.
• Cystitis
  • Cystitis often causes burning upon urination. However, it less likely causes vaginal pruritus and would not explain the discharge that was noted on physical exam.
• Bacterial vaginosis
  • BV may also cause vaginal itchiness/burning but the discharge in BV is typically thin and white/gray and not thick or curd-like. Additionally, it typically has a fishy odor which was not characteristic of the discharge in this pt.

Assessment:

• 26 year old overweight female G2P2002 with complaints of vaginal itching and burning x2 months, since using Plan B. She denies associated symptoms. On exam, thick white curd-like discharge was noted in the cervix and vaginal canal. All other parts of the exam were within normal limits. There are no labs to review at this time. Her presentation is most consistent with vaginal candidiasis.

Diagnosis:

• Vaginal candidiasis

Plan

• Vaginal itching
  • Affirm panel (BV, vaginal candidiasis, trichomoniasis) done
  • STD testing (Chlamydia, gonorrhea, Hep B, Hep C, RPR, HIV) done
  • Empiric treatment for clinical diagnosis of vaginal candidiasis
    • Fluconazole 150 mg tablet once
• Family planning
  • Educated regarding risk of unplanned pregnancy
  • Declined contraception because she is not currently sexually active