Vaginitis is one of the most frequent gynecological diseases characterized by objective and subjective signs of inflammation. The condition is caused by bacterial vaginosis, candidiasis or other non-infectious factors, affecting all age groups of women in their productive years. Common symptoms of vaginitis include vaginal discharge, dyspareunia, and pruritus. The condition can be diagnosed by reviewing the medical history of the patient, perform a pelvic exam and collect a sample of lab testing that can then be used in designing treatment option for the condition.
Subjective data
CC: Vaginal itching with discharge and foul odor for the past one week
History of Present Illness :
The patient is a 22-year black female who presents to the clinic complaining irritation of the genital area and a foul smell coming from the vagina starting about a week ago. She also complains of thin grey vaginal discharge from the itching. The condition usually occurs after she has had intercourse. The patient reports vaginal discharge has a strong foul odor, particularly strong immediately after sex. She has been burning on urination but denies fever, nausea or any vomiting symptoms. Her decision to see a health officer is because she could not stand the odor, burning and vaginal discharge.
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History :
Medical history: The patient does not have any past medical history
Surgical history: The patient does not have any hospitalizations or surgical history
Family history: Her mother who is 48 does not have any known health problems, while her father aged 50 has had a history of hypertension and hyperlipidemia. Her younger sister does not have any known health problems
Social history: The patient is a high school graduate, who is currently living with her boyfriend. She is sexually active and denies any recreational drug or alcohol use for stimulation. The patient also narrates that she keeps her home environment safe all the time free from any physical hazards.
Review of Systems :
General: The patient denies any signs of fever, chills or fatigue. She does not have any weight change or night sweats or lack of appetite. She is alert and oriented and appeared to be well-groomed. She also seems to be well nourished and active
Gastrointestinal: The patient does not have any issues of constipation, hepatitis, eating disorder or any ulcers.
Cardiovascular: She denies any palpitations, chest pain, edema or orthopnea. She also denies respiratory condition such as dyspnea, cough or TB.
Eyes: The patient denies any problems with her eyes such as blurred vision or difficulty focusing. However, she wore contacts and had her last exam over a year.
Skin: The patient does not have any rashes, lumps, nodes or noted skin ulcers, the skin moisture is good, and turgor is intact.
The patient does not have any a headache or head injuries. She denies sinus congestion or drainage or any hearing problem. The patient reports that she had her mental exam within the last six months and denied any bleeding gums or gingivitis.
Current medications, allergies :
The patient has no known drug, food, latex or environmental allergies. She does not have any medical intolerances, chronic illnesses or significant traumas and denies allergic rhinitis or immune deficiencies.
Objective
Vital signs: The patient reports symptoms such as painful urination and blood in urine. She, however, denies back pain. She also reports vaginal irritation and discharge of gray matter with a particularly smelly after sex. However, the patient denies back pain and STDs.
Laboratory data: The urine dipstick was negative from laboratory data. The vaginal examination showed gray thin watery discharge with a foul odor and vaginal swab obtained for microscopic observations. Other lab tests were obtained through wet mount test, vaginal pH test and whiff test. The swap applied to wet amount for whiff amine test, clue cells test and applied to litmus paper for pH tests shows a KOH positive for fishy odor, a PH of 5.2 and presence of clue cells.
Other diagnostic data: Blood pressure 116/74, weight 132 pounds, BMI 20.53, Height 65 inches.
Summary
The primary diagnosis for the condition is vaginitis, which is described as vaginal infection or inflammation that can be caused by infectious and non-infectious diseases. The condition occurs due to changes in the composition of the vaginal microenvironment from irritants, infections or hormonal deficiency ( Han et al., 2015) . The diagnosis of vaginitis is based on symptoms, which is often followed up by further testing. The critical diagnostic factors for vaginitis include vaginal discharge, vaginal dryness and the presence of risk factors such as a change in feminine hygiene products, antibiotic use and douching. The intensity of symptoms for vaginitis depends on the cause, which can be from different infections, some of which can be sexually transmitted, yeast infections or bacterial vaginosis ( Han et al., 2015) . From the symptoms, it can be possible to figure out the most appropriate treatment for the condition.
The secondary diagnosis is cervicitis, which is an inflammation of the cervix caused by several factors such as infections, chemical irritations, and allergies. The symptoms of cervicitis include grayish virginal discharge, abnormal vaginal bleeding as well as painful urination ( Taylor, 2014) . The condition often results from sexually transmitted infections such as chlamydia or gonorrhea, and its treatment entails treating the underlying causes of the inflammation. The disease can also arise from allergic reactions to either latex or feminine hygiene products such as deodorants. The condition can spread to the uterine lining in the patient, resulting in the pelvic inflammatory disease when left untreated and may cause fertility problems.
Another diagnosis for the disease can be gonorrhea, which is a sexually transmitted disease that often causes pain and other symptoms in the genital tract. The differential signs and symptoms of gonorrhea include pelvic or lower abdominal pain in the patient with the presence of fever ( Workowski, 2014). The condition can also cause symptoms such as vaginal discharge, pain when urinating and bleeding between periods. This condition can be passed from one person to another through unprotected sex, and thus the best method of prevention is to use protection or abstinence.
The most common causes of vaginitis in a patient can be treated, though the specific treatment depends on the causal factor in an individual. In this regard, there is a need for a proper diagnosis to achieve effective therapy. Designing the appropriate treatment also requires examining the symptoms to determine causal factors. There is also a recommendation for the patient to screen for sexually transmitted infections to determine the cause and feasible treatment option for vaginitis.
Treatment
The treatment and management for the condition include the use of antibiotic therapy such as metronidazole 500 mg orally twice daily for seven days. Other over the counter drugs to be used are metronidazole gel or clindamycin cream that the patient can apply on the vagina. Alternative therapy is to prevent the condition by avoiding the causal factors ( Nyirjesy, 2014) . For example, the patient can stop using irritants responsible for the irritation such as douching. At the same time, the patient can treat noninfectious vaginitis by pinpointing the source of irritation such as new soap, laundry detergent or tampons and avoid them.
Use of health promotion can also be a preventive measure, involving the provision of education on how to avoid vaginal infection that often leads to vaginitis. The knowledge may entail how to keep the vulva clean and dry and refrain from using agents that can be irritating on the. Non-pharmacological treatment such as seeking to restore normal PH balance by inhibiting the growth of harmful bacteria, such as taking daily yogurt to kill the bacteria that cause vaginosis ( Nyirjesy, 2014) . This treatment can also eliminate the foul fishy odor associated with vaginitis.
References
Han, C., Wu, W., Fan, A., Wang, Y., Zhang, H., Chu, Z., ... & Xue, F. (2015). Diagnostic and therapeutic advancements for aerobic vaginitis. Archives of gynecology and obstetrics , 291 (2), 251-257.
Nyirjesy, P. (2014). Management of persistent vaginitis. Obstetrics & Gynecology , 124 (6), 1135-1146.
Taylor, S. N. (2014). Cervicitis of unknown etiology. Current infectious disease reports , 16 (7), 409.
Workowski, K. (2014). Chlamydia and gonorrhea. Annals of internal medicine , 158 (3), ITC2-1.
