HISTORY:
Vaginal for
, ,
Last menstrual period: ago
Contraception:
Condom use:
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
Pelvic:
- External genitalia: ,
- Vagina: , discharge ,
- Cervix:
- Uterus: ,
- Adnexa: -R , -L
- Tests performed: , , , , vaginal pH , whiff test with KOH
- Performed with chaperone
ASSESSMENT:
DDx:
PLAN:
- Vaginal swab
- Wet mount microscopy
- STI screening for chlamydia and gonorrhea
-
-
-
-
- Avoidance of irritants (soaps, bubble baths, douches, feminine sprays)
- Referral to gynecologist
- Follow-up in
- Return if symptoms do not improve or if develops fever or abdominal pai