Vaginal Itching

Subjective

Martha is a 24-year-old female who presents to the clinic with a 3 day history of vaginal itching. She states that she can barely focus on other things because of the itching. She also reports a copious, white vaginal discharge. Her last Pap smear was at age 21 and was negative. She has not received the HPV vaccine series. Martha denies previous episodes and states that she is otherwise healthy. She denies fever, chills, nausea, vomiting, or diarrhea. She is sexually active and has been with females and males since she was 15 years old. She states that recently she has been exclusively with females but has only had 2 relationships in the past year. She states that she feels somewhat confused about her sexual preferences. She admits to dyspareunia and burning with urination. She denies use of vaginal sprays, douches, or powders or the use of new soaps, detergent, or clothing. Martha does like eating sweets, she admits to wearing a thong regularly.

Past medical history: Tonisillectomy at age 7 years.

Family history: Remarkable for diabetes mellitus and COPD

Social history: Martha is a college graduate and still lives with her widowed mother. She feels safe and has a good relationship with her mother but has not disclosed her sexual preferences to her. Martha does worry about their financial status as she and her mother have two low paying jobs and do not have other financial support. They are currently renting their apartment from a friend.

Medications: None (no antibiotics, steroids, or estrogens)

Allergies: Seasonal in Spring

OBJECTIVE

Vital signs: Martha is afebrile. B/P 110/70, pulse 64 and regular, RR 12 and unlabored, weight 120 lbs., height 5 ft. 3 inches

General: Pleasant and cooperative but seems anxious about the visit.

Cardiac: Regular rate and rhythm

Resp: Lungs CTA

Abd: Soft, nontender, nondistended and without organomegaly.

Pelvic Exam: Inguinal lymph nodes are without swelling or tenderness; vaginal mucosa is moist, pink, and mildly swollen. There is not foul odor; but there is a white cottage cheese-like discharge at the introitus. The cervix is pink and without friability. There is a negative chandelier sign. The pH of the discharge is within normal range (3.8-4.2). The wet prep indicates pseudohyphae.

List at least 3 differential diagnoses (rule in or out by objective data or lab work).
Create an appropriate plan of care for this patient.