History of Present Illness (HPI)

The patient is a sexually active female presenting with complaints of vaginal discharge and vaginal itching for 2 weeks. She reports having unprotected sexual intercourse 4-6 weeks ago. Her last menstrual period was in August, indicating a potential disruption in her menstrual cycle. The patient notes an increase in vaginal discharge.

Differential Diagnosis

• Single Most Likely Diagnosis
  • Bacterial Vaginosis (BV): Given the symptoms of vaginal discharge and itching, along with the patient's history of unprotected sexual intercourse, BV is a strong consideration. It is a common condition in sexually active women and can cause an increase in vaginal discharge.
• Other Likely Diagnoses
  • Yeast Infection (Candidiasis): This is another common cause of vaginal itching and discharge, especially in sexually active women. The symptoms can be similar to BV, making it a likely differential.
  • Trichomoniasis: A sexually transmitted infection that can cause vaginal discharge, itching, and irritation. The patient's history of unprotected sex increases the likelihood of this diagnosis.
  • Chlamydia or Gonorrhea: These sexually transmitted infections can cause vaginal discharge and itching, among other symptoms. Given the patient's recent unprotected sexual activity, these should be considered.
• Do Not Miss Diagnoses
  • Pelvic Inflammatory Disease (PID): While the patient's symptoms do not directly suggest PID, it is a serious condition that can result from untreated sexually transmitted infections. Missing this diagnosis could lead to severe consequences, including infertility and chronic pelvic pain.
  • Ectopic Pregnancy: Given the patient's report of her last menstrual period being in August and recent unprotected sex, an ectopic pregnancy must be considered, especially if she is experiencing any abdominal pain or other symptoms suggestive of pregnancy.
• Rare Diagnoses
  • Vulvar Cancer: Although extremely rare and unlikely in a young, sexually active woman without other risk factors, any persistent or unusual vaginal symptoms could potentially be a sign of a more serious condition like vulvar cancer.
  • Desquamative Inflammatory Vaginitis (DIV): A rare condition characterized by vaginal inflammation and discharge. It is less common than other causes of vaginal discharge but should be considered if other diagnoses are ruled out.