NAME:

BLOCK

UNIT 27
(CASE #2)
General Data:
Age/Sex: 29 years old/Female

Chief Complaint: Vaginal discharge

History of Present Illness

Onset: Few days after sexual intercourse with her new partner
Precipitating factor: Sexual intercourse
Quality: yellowish discharge
Relieving Factors: --
Associated signs and symptoms: dysuria, urinary frequency

Past Medical History:

• Ultrasound (2020): small myoma, no follow up done
• Vaccination (last year): 3 doses Gardasil 4
• No gynecologic procedures done

OB-Gyne History:

LMP: April 17, 2022

Interval: Irregular (no menses for 1-2 months)

OB Score: G3P2 (2-0-1-2)

Gravida: 3 Parity: 2
Term: 2 Preterm:0 Abortion:1 Living:2

Duration of menses: 4-5 days

Flow: moderate
No. of pads per day:1-2 pads on the first 2 days then 1-2 panty liners during the succeeding
days
Dysmenorrhea: none
Family planning method: ---
Papsmear: 3 Papsmears (with unremarkable result)
Last sexual contact: ---
No. of sexual partners: 2
Age of menopause: ---

Personal and Social History:

• First sexual contact at 20 years; has had 5 partners
• Polygamous

Family History: ---

 Review of Systems:
General: ---
Skin: ---
HEENT: ---
Breasts: ---
Respiratory: ---
Cardiovascular: ---
Gastrointestinal: ---
Peripheral Vascular: ---
Genitourinary: (+) dysuria, frequency, discharge
Musculoskeletal: ---
Neurologic: ---
Psychiatric (if relevant): ---

Guide questions:

1. Describe the physical examination.

General
Vital Sign BP: 110/80 mmHg
CR: 88 bpm
RR:19 cpm
T:36.1 C
Skin --
HEENT --
Chest --
Cardiovascular --

Abdomen flat, vertical infraumbilical scar 2 fingerbreadths below the

umbilicus and 3 fingerbreadths above the symphysis pubis, no
masses seen, normoactive bowel sounds, no masses palpated, no
tenderness
Genitourinary External genitalia and Speculum exam:
 Erythematous vulva

Copious, frothy, whitish to yellowish discharge

 Strawberry cervix (punctate hemorrhagic spots on the cervix)

Internal examination and bimanual exam:

Introitus: admit 2 fingers with ease, palpable vaginal ruggae, no

masses, no tenderness

cervix: posterior, closed, long, firm, no wiggling tenderness, no

mass

uterus: midline, unenlarged, no tenderness, no adnexal mass or

tenderness, (upon removal of) examining fingers with yellowish
discharge, no blood

Extremities ---

2. Give at least 2 differential diagnoses.

3. What are the bases for your differentials?
 Patient Trichomoniasis Bacterial Vaginosis Vulvovaginal
Vaginitis candidiasis
Risk Factors
29-year-old; female (+) (+) most common in
More common in It occurs in adult reproductive-age
women; 14- 49 women; child-bearing women
years old age
Sexual History (+) Not an STI, but can
- has had 5 partners Multiple sex occur concomitantly
- in a polygamous partners with sexually
relationship (at transmitted diseases
(+)
present with 2 (STDs)
Multiple sexual
sexual partners) partners
- Sexual history of may be linked to
partners unknown orogenital and, less
to the patient. commonly,
anogenital sex
3 doses of Gardasil 4 (-)
vaccine Does not protect
(-) (-)
against
trichomoniasis
Subjective Findings
abnormal vaginal (+)
discharge a few days Green or yellow
after she had sexual vaginal discharge (+) +
intercourse that is sometimes Increased vaginal Abnormal vaginal
frothy, profuse, or discharge discharge
both. It may smell
fishy
burning sensation (+) +
when urinating Dysuria and more (+) Burning sensation in
frequent urination the vagina and vulva
urinates more than -
(-)
usual
Objective Findings
External genitalia (+) - Usually, - erythema and
and speculum exam: Strawberry cervix normal edema of the
- Purulent secretion or colpitis appearance of vestibule and of
with mucosal macularis tissue; the labia majora
erythema - Homogeneous and minora
(Copious, frothy, Vulvar erythema discharge that - rash may extend
whitish to adheres to to the thighs and
yellowish vaginal walls perineum
discharge) - Thrush patches
- cervical mucosa are usually found
reveals punctate loosely adherent
hemorrhages, to the vulva
along with
accompanying
 vesicles or
papules
- Erythematous
vulva
- Strawberry cervix
(punctate
hemorrhagic spots
on the cervix)
Uterus: upon (+) vaginal discharge is
removal of green or yellow usually thin but may
Thin, off-white
examining fingers vaginal discharge contain whitish
discharge
with yellowish “curds”
discharge

Other differentials:
• Infectious cervicitis
• Chlamydia

4. What is the patient’s problem list?

a) Possible Trichomoniasis
b) History of Irregular Menstrual Cycle
c) History of Myoma
d) High-risk sexual activity

#1 Possible Trichomoniasis
Abnormal vaginal discharge
Dysuria
Polyuria
Frothy whitish to yellowish discharge upon examination of the uterus
Purulent secretions seen in the external genitalia
Erythematous vagina
Strawberry Cervix
Cervical mucosa reveals punctate hemorrhages, along with accompanying vesicles or
papules
#2 History of Myoma
Small myoma found in ultrasound last
#3 High-risk sexual activity
Sexually active and has been with 5 partners already with the current one being a
polygamous relationship
#4 History of irregularity in menstrual cycles
References:

Girerd, P. H., MD. (2022, January 28). Bacterial Vaginosis Clinical Presentation: History,
Physical Examination. Medscape. https://emedicine.medscape.com/article/254342-
clinical#b1

Lipsky, E. M. E. S. (2000, September 1). Diagnosis of Vaginitis. American Family Physician.

https://www.aafp.org/afp/2000/0901/p1095.html#sec-2

Smart, S. (2004, February 1). Social and sexual risk factors for bacterial vaginosis. Sexually
Transmitted Infections. https://sti.bmj.com/content/80/1/58

Smith, S. (2022, February 8). Trichomoniasis: Background, Pathophysiology, Etiology.

Medscape.com; Medscape. https://emedicine.medscape.com/article/230617-overview