Level 2: Vaginal Discharge – Contrasting Case #1: Patient Information

Given these changes from the original case, what is your diagnosis?

What is your diagnostic explanation?

As compared to the long case, this patient is a 25 year old female who presents to Urgent Care with vaginal discharge. She states that over the past few days she has begun to notice vaginal discharge. Discharge has increased in amount and is malodorous. She states that she also has significant vaginal itching/burning and irritation. She is currently sexually active with one partner. She currently uses birth control as a means of contraception.

PMH, SH, and FMH: All the same as in the long case.

ROS –
General: No fatigue, fevers, chills.
GI: No nausea/vomiting. No diarrhea/constipation.
GU: Mild dysuria. No hematuria. Increased urinary frequency. Odorous vaginal discharge. Vaginal itching and burning.

PE –
VS: Height 5’5” Weight 150lb BMI 25 HR82 BP120/80 RR16 98.5F
Cardiac: S1 and S2 audible. Regular rate and rhythm. No murmurs
Lungs: Clear to auscultation bilaterally. No adventitious sounds present.
Abdomen: Soft, nontender, nondistended. No organomegaly present.

GU: Thin malodorous vaginal discharge present. Labia majora are red and inflamed. Vaginal walls are erythematous.