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Case 6.5 Vaginal Itching

By Sara Smoller, RN, MSN, ANP‐BC

SUBJECTIVE

Martha is a 24‐year‐old female who reports vaginal itching for 3 days. She says 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 22 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 with both male and female partners since the age of 15. She states that recently she has been exclusively with females but has had 2 sexual partners in the past year. She states that she still 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. Her last menstrual period (LMP) was 3 weeks ago.

Past medical history: Recurrent strep pharyngitis—last episode 3 weeks ago.

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 mother. Martha does worry about their financial status as she and her mother have low‐paying jobs and do not have other financial support. They are currently renting their apartment from a friend. Martha does not smoke and denies substance use.

Medications: None currently. She completed a 10‐day course of amoxicillin 1 week ago for strep pharyngitis.

Allergies: Seasonal in spring.

OBJECTIVE

Vital signs: Martha is afebrile. Her BP is 110/70. Pulse is 64 and regular. Respirations are 12 and unlabored. She is 5 ft 3 inches tall and weighs 120 lbs.

General: Martha is pleasant and cooperative but seems anxious about the visit.

Throat: No swelling or exudates.

Cardiac: Regular rate and rhythm.

Respiratory: Lungs are clear bilaterally.

Abdomen: 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 no foul odor; but there is a white, cottage cheese–like discharge at the introitus. The cervix is pink and without friability. There is no cervical motion tenderness (CMT). The pH of the vaginal discharge is within normal range (3.8–4.2).

CRITICAL THINKING

1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Pap smear___Cultures for gonorrhea and chlamydia___Urine testing for gonorrhea and chlamydia___Wet mount, including KOH and whiff test___Urinalysis

2 If a wet mount were performed, what findings would be expected for the following diagnoses?Bacterial vaginosisCandidiasisTrichomonas

3 What is the most likely differential diagnosis and why?___Bacterial vaginosis___Candidiasis___Trichomonas___Gonorrhea___Chlamydia___Herpes simplex___Urinary tract infection

4 What is the plan of treatment?

5 What education should be provided to Martha at this visit?

6 Are any referrals needed?

7 Is the family history of diabetes relevant to this case?

8 How can the clinician support the patient regarding her confusion with her sexual preferences?

NOTE: The author would like to thank Leslie Neal‐Boylan, PhD, APRN, CRRN, FAAN, FARN for her contribution to this case in the first edition of this book.