Chief Complaint (CC)
The patient reports itchiness and burning feeling in the vaginal area.
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History of Present Illness (HPI)
A twenty-six-year-old female with no known medical history presents a complaint of vaginal inflammation and irritation. The symptoms appeared two weeks ago and have been consistent. The patient has no history of previous vaginal infections or pains. She denies any sexual encounters during that period. The patient admits to using new hygiene products.
Last Menstrual Period (LMP)
LMP started three weeks ago, according to the regular schedule. The period had no additional discharge or uncharacteristic pains.
Past Medical History
The patient is up to date on all vaccinations. No medical history of previous gynecological problems is present. The patient has no history of pregnancy. The patient never reported to have allergies and did not perform any sensitization tests.
The patient’s family has no relevant medical evidence. Father has a history of controlled hypertension. No further conditions are present. According to the patient, the mother has no major history that concerns the present issues.
The patient has no history of surgery.
The patient has no pregnancy history.
Social History (Alcohol, Drug, or Tobacco Use)
The patient denies any drug or tobacco use, admits to rare recreational drinking. Overall safety status is adequate. The patient lives alone and has a steady job, which she describes as non-stressful. She recently started exercising. She showers at the gym after the exercise, where she uses new hygiene products.
The patient does not take any medications.
Review of Systems
- General: The patient reports no recent bodyweight problems. She denies weight loss or weight gain, difficulty sleeping, tiredness, loss of appetite.
- Cardiovascular: The patient denies any chest pain, dyspnea, edema, or palpitations.
- Dermatology: The skin of the vulva is red and tender, without any plaques or blisters. No visible redness or irritation present in other areas of the body.
- Respiratory: The patient denies any breathing problems or cough.
- Genitourinary/Gynecological: The patient denies changes in urgency. No recent history of bleeding or incontinence is present. The patient has regular monthly periods.
- Gastrointestinal: The patient has no complaints or abdominal pain. No reflux, nausea, or loss of appetite.
- Eyes, nose, mouth, and ears: The patient denies oral problems, nasal congestion, hearing problems.
- Musculoskeletal: The patient denies muscle pain, joint pain, swelling, or stiffness.
- Breast: No breast complaints are present.
- Neurologic: The patient denies headaches, seizures, dizziness, or memory problems.
- Psychiatric: The patient denies anxiety, depression, frequent mood changes, or insomnia.
- Hematologic: The patient denies anemia or unusual bleeding.
- Allergic: The patient has no history of allergies. She denies allergy testing, seasonal, and food allergies. No history of family allergies is present.
- Height: 5’9”.
- Weight: 154 lb.
- Temp: 98.3 F.
- Pulse: 78 BPM.
- BP: 123/80.
The patient is a healthy-appearing and well-nourished female with no visible health problems or distress. She answers questions clearly and adequately and tells information about her family and health history without any problems.
Integument: Overall, the patient’s skin is dry, warm, and intact. There is no scaling, redness, or tenderness on the upper body or legs. The skin around the vulva is inflamed and tender, no ulcers or injuries are present.
Cardiovascular: Heartbeat is normal, has regular rate and rhythm, no murmurs, gallops, clicks, or rubs. There is no edema, cyanosis, or clubbing present.
Respiratory: Both lungs are clear to auscultation, no wheezing, or other sounds. Breathing is even and unobstructed.
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Gastrointestinal: Abdomen is soft and non-tender. No masses, BS is present.
Genitourinary/Gynecological: No bladder tenderness to palpation. The sensitivity of external genitalia is heightened, the skin is irritated, and touching the skin evokes distress and pain. Vagina shows reddened mucosa with no lesions. Vaginal discharge is white and minimal.
Lab work: Not available.
Candida is an infectious type of vaginitis, caused by a fungus Candida, or yeast (National Institutes of Health, 2017). There are multiple reasons for the yeast to fall out of normal balance. Upsetting the balance of the bacteria that normally reside in the area with antibiotics, pregnancy, and changes in the immune system can cause the yeast to overgrow and become an infection. The symptoms of a yeast infection include thick white vaginal discharge and irritation of the vulva and vagina (National Institutes of Health, 2017).
According to Powell and Nyirjesy (2015), the patient’s vaginal discharge is not a sign of a yeast infection, because it does not have a thick cottage cheese consistency. Moreover, the patient has no recent history of taking antibiotics or having other infections that might affect the immune system. Candida can be ruled out.
Bacterial vaginitis or vaginosis can be caused by the overgrowth of certain bacteria in the vagina. According to Bafghi, Hoseizadeh, Jafari, and Naghshi (2014), its symptoms usually include white or gray vaginal discharge, itching and burning of the vagina, a strong odor, burning during urination, and pain and irritation of the vulva. While some symptoms align, the patient does not report to have a burning feeling during urination.
The vaginal discharge is not excessive, and the color of it is not gray, which can also rule out bacterial vaginitis. Moreover, there is no fish-like odor, which is often described as one of the most evident symptoms of bacterial vaginitis (Centers for Disease Control and Prevention, 2017). However, some precautions should be taken by the patient to prevent the possible development of bacterial vaginitis in the future (Nyirjesy, 2014).
This type of vaginitis can be caused by an allergen and can be easily avoided and treated. Possible causes of noninfectious vaginitis include various douches, sprays, and creams as well as some perfumes, soaps, and fabric softeners (National Institutes of Health, 2017). The most common symptoms of noninfectious vaginitis include irritation of the vagina and the vulva, reddening, itchiness of the skin, and possible vaginal discharge (Faro, 2015). If an individual with this type of vaginitis removes the irritant, the symptoms should go away. The patient admitted to having a new routine and using new hygiene products, which can irritate.
The patient presents such symptoms as itchiness and redness of the tissue around vulva and vagina. She does not report to have a burning feeling during urination. There is no unhealthy or unusual vaginal discharge or odor. Moreover, the patient confirms that she uses new hygiene products that come in contact with the pelvic area. The timelines of using new products and the development of the symptoms also align. Therefore, it is possible to conclude that the patient has noninfectious vaginitis.
The patient needs to remove the irritant and switch to hypoallergenic hygiene products. To ameliorate the symptoms, the patient can use an estrogen cream vaginally. A sensitization test should be conducted to establish possible allergens. Age-appropriate screenings are advisable. Education on the topic of vaginal health and bacterial balance as well as additional information on hypoallergenic cosmetics and products is required. There is no need for additional cultural considerations.
The follow-up appointment is scheduled in two weeks to see if the reaction of the skin to the allergen has gone away. Tests for allergens should be prepared at this time to establish the accuracy of the diagnosis. If the symptoms persist or change, discussing further actions with the patient and providing support is necessary.
Bafghi, A. F., Hoseizadeh, A., Jafari, A. A., & Naghshi, M. (2014). Frequency distribution of bacterial vaginosis in women referred to health centers in Yazd city. Journal of Biological Pharmaceutical and Chemical Research, 1(1), 179-185.
Centers for Disease Control and Prevention. (2017). Bacterial vaginosis (BV). Web.
Faro, S. (2015). Vaginitis and cervicitis. In D. Schlossberg (Ed.), Clinical Infectious Disease (2nd ed.)(pp. 392-410). Cambridge, UK: Cambridge University Press.
National Institutes of Health. (2017). Vaginitis: Overview. Web.
Nyirjesy, P. (2014). Management of persistent vaginitis. Obstetrics & Gynecology, 124(6), 1135-1146.
Powell, A. M., & Nyirjesy, P. (2015). New perspectives on the normal vagina and non-infectious causes of discharge. Clinical Obstetrics and Gynecology, 58(3), 453-463.