Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chief complaint of intense vulvar pruritus, burning, and vaginal soreness. Reports thick, white, curd-like vaginal discharge. Denies malodor, dysuria (unless secondary to vulvar excoriation), or systemic symptoms. No recent antibiotic use or change in hygiene products noted.
Clinical Examination Findings
External genitalia: Erythema and edema of the labia majora and minora, with excoriations present. Speculum exam: Vaginal mucosa shows significant erythema and adherent white, cheesy plaques. Fornices clear. Bimanual exam: No cervical motion tenderness or adnexal tenderness. pH of vaginal secretions: 4.0β4.5. Saline/KOH wet mount: Budding yeast and pseudohyphae identified.
Treatment Protocol
Diagnosis: Vulvovaginal Candidiasis (ICD-10: B37.3). Plan: Initiate antifungal therapy. 1. Fluconazole 150 mg PO single dose OR 2. Clotrimazole 1% cream or Miconazole 2% cream intravaginally for 3β7 days. Advise patient to avoid irritants, maintain dry genital area, and wear loose-fitting cotton underwear. Follow up if symptoms persist beyond 72 hours.