Obgyn · Year 3 · from Obgyn
Case 3: Vaginitis Evaluation with Wet Mount
Patient Demographics
- Age: 28 years
- Sex: Female
- Occupation: Veterinary assistant
Chief Complaint
"I have vaginal discharge and itching that won't go away."
History of Present Illness
The patient presents with a 1-week history of vaginal discharge and intense vulvar itching. The discharge is thick, white, and "cottage cheese-like." The itching is worse at night and she has been unable to sleep well. She has tried over-the-counter yeast treatment (miconazole cream x 3 days) without improvement. She denies fever, abdominal pain, or dysuria. She is sexually active with one male partner (together 2 years) and uses oral contraceptive pills.
Gynecologic History
- Menarche: Age 13
- Cycles: Regular with OCP use
- LMP: 1 week ago (finished period)
- Contraception: Combined OCP x 5 years
- STI history: None
- Sexual history: Monogamous, no new partners
Past Medical History
- Recently completed antibiotics (amoxicillin) for sinusitis 2 weeks ago
- No diabetes
- No immunocompromising conditions
Physical Examination
External Genitalia:
- Vulvar erythema and edema
- Excoriations from scratching
- No ulcers or lesions
Speculum Examination:
- Thick, white, curd-like discharge adherent to vaginal walls
- Vaginal erythema
- Cervix appears normal, no discharge from os
- No cervical motion tenderness
Diagnostic Testing
Vaginal pH: 4.0 (normal: 4.0-4.5)
Wet Mount Microscopy:
- Saline prep: Epithelial cells present, no clue cells, no trichomonads
- 10% KOH prep: Budding yeast and pseudohyphae present
- Whiff test: Negative (no fishy odor)
Findings Summary:
| Test | Result | Interpretation |
|---|---|---|
| pH | 4.0 | Normal (not BV) |
| Clue cells | Absent | Not BV |
| Trichomonads | Absent | Not trichomoniasis |
| Yeast/Hyphae | Present | Candidiasis |
| Whiff test | Negative | Not BV |
Diagnosis
Vulvovaginal Candidiasis (Yeast Infection) - Complicated
- Severe symptoms
- Recent antibiotic use (predisposing factor)
- Failed initial OTC treatment
Treatment
First-line for complicated candidiasis:
- Fluconazole 150 mg PO now, repeat in 72 hours (two-dose regimen)
Adjunctive measures:
- Cool compresses for vulvar discomfort
- Avoid scented products, douching
- Wear cotton underwear
- Return if no improvement in 1 week
Patient Education
- Antibiotics disrupt normal vaginal flora, allowing yeast overgrowth
- This is not a sexually transmitted infection; partner treatment not needed
- Recurrent candidiasis (4+ episodes/year) may require suppressive therapy
Follow-up
- Called patient at 1 week: Symptoms resolved
- Counseled on preventing recurrence with future antibiotic courses
Differential Diagnosis Comparison
| Condition | Discharge | pH | Wet Mount | Odor |
|---|---|---|---|---|
| Candidiasis | Thick, white, curd-like | Normal (4-4.5) | Pseudohyphae, budding yeast | None |
| Bacterial Vaginosis | Gray, thin, homogeneous | >4.5 | Clue cells | Fishy (positive whiff) |
| Trichomoniasis | Green-yellow, frothy | >4.5 | Motile trichomonads | May be fishy |
| Normal | Clear to white | 4.0-4.5 | Epithelial cells, lactobacilli | None |
Clinical Image
Image Description: Microscopic image of a KOH preparation from vaginal discharge demonstrating budding yeast cells and pseudohyphae characteristic of vulvovaginal candidiasis. The branching pseudohyphae appear as elongated structures with visible septations.
Attribution: Image from CDC Public Health Image Library. Public domain.