37-Year-Old Woman with Vulvovaginal Candidiasis SOAP Note
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37-Year-Old Woman with Vulvovaginal Candidiasis SOAP Note
Patient’s ID:
ID: A.S., DOB 02/15/1987, age 37, is an African American female who presents to the clinic
alone and appears to be a reliable historian.
SUBJECTIVE:
Chief Complaint (CC):
"I have been experiencing itching and a thick, white discharge down there."
HPI:
A.S., a 37-year-old African American female, presents with complaints of vaginal itching and
discharge that started one week ago. The discharge is described as thick, white, and clumpy,
similar to cottage cheese. She reports the itching as severe, particularly around the vulva, which
is also red and swollen. There is no foul odour associated with the discharge. A.S. also notes
mild burning during urination but denies pain during intercourse. She mentions these symptoms
have occurred occasionally in the past but has resolved without treatment. The patient denies any
fever, chills, or abdominal pain. She reports using scented soaps and wearing tight-fitting,
synthetic underwear, which she suspects might have aggravated the condition.
Past Medical and Surgical History:
Medical Problem List:
Type 2 Diabetes: Diagnosed two years ago.
Preventative Care:
Influenza Vaccine: Last received in February 2024.
Covid Vaccine: The last booster was received in November 2023.
Tdap Vaccine: Last received in July 2020.
Mammogram: Last performed in June 2022 with normal results.
Surgeries:
None.
Hospitalizations:
None.
Allergies:
Food: None.
Drug: None.
Environmental: None.
Medications:
Metformin 500 mg twice daily for type 2 diabetes.
Family History:
Father: Alive, age 68, has chronic kidney disease.
Mother: Deceased, age 65, from complications of type 2 diabetes.
Siblings: One sister, age 35, with no significant medical history.
Paternal Grandfather: Deceased, age 70, had Alzheimer’s disease.
Paternal Grandmother: Deceased, age 72, had rheumatoid arthritis.
Maternal Grandfather: Deceased, age 68, had prostate cancer.
Maternal Grandmother: Deceased, age 75, had Parkinson’s disease.
Social History:
Sexual History: Married, in a monogamous relationship. No history of sexually transmitted
infections.
Chemical History:
Tobacco: Never smoked.
Alcohol: Social drinker, consumes approximately 1-2 drinks per week, usually on weekends.
Drugs: Denies use of recreational or illicit drugs.
Diet: Follows a balanced diet that includes a variety of fruits, vegetables, lean proteins, and
whole grains. Occasionally indulges in fast food and desserts.
Exercise: Regularly participates in physical activities, including jogging and yoga, three times a
week. Enjoys cycling and outdoor activities with family on weekends.
Spirituality: Identifies as Christian, attends church services weekly, and participates in church
community activities.
Work: Employed as a hotel attendant, finds the job physically demanding but enjoys interacting
with guests. Experiences moderate stress during peak tourist seasons.
Living Arrangements: Lives with her spouse and one child in a suburban home.
Children: One child, aged 10, healthy and active. Maintains a close and nurturing relationship
with the child.
ADLs (Activities of Daily Living): Fully independent in all activities of daily living, including
household chores, cooking, and personal care.
Review of Systems:
Constitutional: Reports mild fatigue. Denies fever, weight loss, or night sweats.
HEENT: Denies head trauma, visual changes, eye pain, or discharge. No complaints of hearing
loss, tinnitus, ear pain, or sore throat.
Respiratory: Denies shortness of breath, cough, or wheezing.
Cardiovascular: Denies chest pain, palpitations, or leg swelling.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, or diarrhoea. Reports normal bowel
movements.
Genitourinary: Reports vaginal itching, thick white discharge, and mild burning on urination. No
foul odor or pelvic pain.
Musculoskeletal: Denies joint pain, muscle weakness, or back pain. Reports occasional mild
stiffness in the mornings.
Neurological: Denies headaches, dizziness, syncope, or seizures: no numbness or tingling.
Psychiatric: Denies depression, anxiety, or sleep disturbances. Reports feeling generally well
mentally.
Endocrine: Denies excessive thirst, frequent urination, or heat/cold intolerance.
Hematologic/Lymphatic: Denies easy bruising, bleeding, or lymph node swelling.
OBJECTIVE:
VS: BP: 118/76 mmHg, HR: 72 bpm, RR: 16 breaths/min
Temp: 98.4°F, SpO2: 98% on room air.
Height: 5'6", Weight: 150 lbs, BMI: 24.2 kg/m² (Normal weight).
Labs, Radiology or Other Pertinent Studies:
Wet Mount Preparation: Shows budding yeast and pseudohyphae, consistent with
vulvovaginal candidiasis.
Physical Exam:
General: A.S. appears well-nourished, well-developed, and in no acute distress.
Genitourinary: External genitalia shows erythema and oedema of the vulva. Thick, white,
clumpy discharge noted. No lesions or ulcers. No inguinal lymphadenopathy. On inspection,
there is significant erythema and oedema. Palpation reveals tenderness in the vulvar area.
HEENT: Normocephalic, atraumatic. PERRLA (pupils equal, round, and reactive to light and
accommodation). EOMI (extraocular movements intact). Mucous membranes are moist.
Respiratory: Clear to auscultation bilaterally. No wheezing, rales, or rhonchi. On inspection, no
deformities or use of accessory muscles were noted. Palpation reveals symmetrical chest
expansion. Percussion is resonant throughout.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. On inspection, there
were no visible pulsations or abnormalities. Palpation reveals normal peripheral pulses.
Percussion of the precordium shows normal heart borders. Auscultation reveals clear heart
sounds.
Abdomen: Soft, non-tender, no organomegaly. On inspection, the abdomen appears normal with
no enlargement. Palpation reveals no masses or tenderness. Percussion is tympanic over the
intestines. Auscultation reveals normal bowel sounds.
Musculoskeletal: Full range of motion in all extremities. No swelling or tenderness. On
inspection, there were no deformities or abnormalities. Palpation reveals no tenderness or
masses. Normal muscle strength is observed during auscultation of joint movement.
Psychiatric: Alert and oriented, normal mood and affect. Inspection shows no signs of distress or
anxiety. The patient communicates clearly and logically during the examination.
ASSESSMENT:
Differentials Diagnosis:
a) Vulvovaginal Candidiasis ICD-10: B37.3: Vulvovaginal candidiasis is a common
fungal infection caused by Candida species, most frequently Candida albicans. It
typically presents with intense vaginal itching, thick white discharge resembling cottage
cheese, erythema, oedema of the vulva, and sometimes mild burning during urination
(Benedict et al., 2022). This is the most likely diagnosis for A.S. due to her reported
symptoms of severe vaginal itching, thick white discharge, and mild burning on
urination. The physical exam findings of erythema and oedema of the vulva, along with
the presence of budding yeast and pseudohyphae on the wet mount preparation, confirm
the diagnosis. Her history of using scented soaps and tight-fitting, synthetic underwear
could be contributing factors, making this diagnosis consistent with her clinical
presentation.
b) Acute Vaginitis ICD-10: N76.0: Acute vaginitis refers to the inflammation of the
vagina, often caused by bacterial, viral, or parasitic infections or by irritants. It can
present with vaginal discharge, itching, burning, and sometimes an unpleasant odour. The
discharge may be grey, yellow-green, or frothy, and there might be discomfort or pain
during intercourse (Neal et al., 2020). While A.S. does present with vaginal itching and
discharge, the characteristics of her discharge are more indicative of candidiasis rather
than the more varied discharge seen in vaginitis. Additionally, there is no mention of a
foul odour, which is often associated with bacterial vaginitis. The lack of systemic
symptoms like fever or significant pain further supports that vulvovaginal candidiasis is
more likely than acute vaginitis in this case.
c) Trichomoniasis ICD-10: A59.0: Trichomoniasis is a sexually transmitted infection
caused by the protozoan parasite Trichomonas vaginalis. It often presents with frothy,
yellow-green vaginal discharge, vaginal and vulvar irritation, itching, and a foul-smelling
odour. There can also be discomfort during urination and intercourse (Lindrose et al.,
2022). A.S.'s symptoms do not align well with trichomoniasis. She describes her
discharge as thick and white, without the bubbly, yellow-green characteristic of
trichomoniasis. Moreover, the absence of a foul smell and significant discomfort during
intercourse reduces the likelihood of trichomoniasis being the correct diagnosis. The
clinical presentation and wet mount findings strongly point to vulvovaginal candidiasis as
the primary diagnosis over trichomoniasis.
Final Diagnosis:
Vulvovaginal Candidiasis ICD-10: B37.3: A.S.'s symptoms of severe vaginal itching, thick
white discharge, and mild burning on urination, combined with the physical exam findings of
erythema and oedema of the vulva, strongly suggest vulvovaginal candidiasis. Vulvovaginal
candidiasis is a common fungal infection caused by an overgrowth of Candida species,
particularly Candida albicans, in the vaginal area (Benedict, Lyman et al., 2022). The wet Mount
preparation showing budding yeast and pseudohyphae confirms this diagnosis. Her history of
using scented soaps and wearing tight-fitting, synthetic underwear likely contributed to the
development of this condition. This diagnosis is consistent with her clinical presentation and is
supported by both subjective and objective findings.
PLAN:
Diagnostics:
a) Wet Mount Preparation: A microscopic examination of a sample of vaginal discharge
mixed with saline on a glass slide to identify the presence of yeast cells, pseudohyphae,
and other organisms (Vieira-Baptista et al., 2021). This test is crucial for confirming the
diagnosis of vulvovaginal candidiasis by visualizing the characteristic budding yeast and
pseudohyphae, which indicate a fungal infection. Findings: Budding yeast and
pseudohyphae are shown, consistent with vulvovaginal candidiasis.
b) Vaginal Swab Culture: A laboratory test where a sample of vaginal discharge is
cultured to identify the specific Candida species and to check for antifungal resistance
(Vieira-Baptista et al., 2021). This test is important if symptoms persist or recur to ensure
appropriate treatment by identifying the exact pathogen and its susceptibility to
antifungal medications. Findings: Candida Albicans seen.
Treatment:
a) Fluconazole 150 mg oral tablet, single dose: Fluconazole belongs to the class of
antifungal medications known as triazoles. It works by inhibiting the enzyme lanosterol
14-α-demethylase, which is necessary for converting lanosterol to ergosterol, an essential
component of fungal cell membranes (Phillips et al., 2022). This inhibition results in
increased membrane permeability and ultimately leads to the death of the fungal cells.
b) Topical Clotrimazole cream, 1% applied twice daily for 7 days: Clotrimazole is an
antifungal medication that belongs to the class of imidazoles. It acts by inhibiting the
synthesis of ergosterol, a key component of the fungal cell membrane, through the
inhibition of the enzyme lanosterol 14-α-demethylase (San et al., 2023). This disruption
of the cell membrane's integrity leads to increased permeability and cell death. Topical
application of clotrimazole provides localized treatment, directly targeting the affected
area to relieve symptoms such as itching and irritation.
Education:
a. Emphasize the importance of completing the full course of prescribed medications, even
if symptoms improve before the treatment is finished, to ensure the infection is fully
eradicated (Sim et al., 2020).
b. Advise avoiding the use of scented soaps, douches, and tight-fitting, synthetic underwear,
as these can disrupt the normal vaginal flora and exacerbate symptoms (Sim et al., 2020).
c. Encourage maintaining good vaginal hygiene by washing the genital area with mild,
unscented soap and water (Sim et al., 2020)
d. Suggest following a balanced diet and reducing sugar intake, which can promote yeast
growth. Emphasize the importance of a diet rich in fruits, vegetables, lean proteins, and
whole grains (Pfieffer, 2022).
e. Discuss the potential for recurrence and the importance of seeking prompt treatment if
symptoms return. Advise patients to be mindful of factors that could trigger another
infection (Sim et al., 2020).
f. Educate the patient on the warning signs of recurrence, such as itching, discharge, and
irritation, and advise them to seek medical attention if these symptoms reappear (Sim et
al., 2020).
g. Explain that stress can weaken the immune system and make the body more susceptible
to infections. Encourage stress-reducing activities such as exercise, meditation, or
hobbies (Sim et al., 2020).
h. Schedule a follow-up appointment in two weeks to assess the resolution of symptoms and
adjust the treatment plan if necessary (Pfieffer, 2022).
Follow-up: Return for a follow-up appointment in two weeks to check symptom resolution.
Referral: Refer to a gynaecologist if symptoms persist despite treatment or if there are recurrent
infections.
References
Benedict, K., Lyman, M., & Jackson, B. R. (2022). Possible misdiagnosis, inappropriate empiric
treatment, and opportunities for increased diagnostic testing for patients with
vulvovaginal candidiasis—United States, 2018. PLOS ONE, 17(4), e0267866.
https://doi.org/10.1371/journal.pone.0267866
Benedict, K., Singleton, A. L., Jackson, B. R., & Molinari, N. A. M. (2022). Survey of incidence,
lifetime prevalence, and treatment of self-reported vulvovaginal candidiasis, United
States, 2020. BMC Women’s Health, 22(1). https://doi.org/10.1186/s12905-022-01741-x
Lindrose, A. R., Htet, K. Z., O’Connell, S., Marsh, J., & Kissinger, P. J. (2022). Burden of
trichomoniasis among older adults in the United States: a systematic review. Sexual
Health. https://doi.org/10.1071/sh22009
Neal, C. M., Kus, L. H., Eckert, L. O., & Peipert, J. F. (2020). Noncandidal vaginitis: a
comprehensive approach to diagnosis and management. American Journal of Obstetrics
and Gynecology, 222(2), 114–122. https://doi.org/10.1016/j.ajog.2019.09.001
Pfieffer, M. L. (2022). Recurrent Vulvovaginal Candidiasis. Advances in Family Practice
Nursing, 4(1), 117–129. https://doi.org/10.1016/j.yfpn.2021.12.006
Phillips, N., Bachmann, G., Haefner, H. K., Martens, M. G., & Stockdale, C. K. (2022). Topical
Treatment of Recurrent Vulvovaginal Candidiasis: An Expert Consensus. Women’s
Health Reports, 3(1), 38–42. https://doi.org/10.1089/whr.2021.0065
San, J., Poliquin, V., & Aleeza Cara Gerstein. (2023). Insights and advances in recurrent
vulvovaginal candidiasis. PLOS Pathogens, 19(11), e1011684–e1011684.
https://doi.org/10.1371/journal.ppat.1011684
Sim, M., Logan, S., & Goh, L. (2020). Vaginal discharge: evaluation and management in
primary care. Singapore Medical Journal, 61(6), 297–301.
https://doi.org/10.11622/smedj.2020088
Vieira-Baptista, P., Grincevičienė, Š., Oliveira, C., Fonseca-Moutinho, J., Cherey, F., &
Stockdale, C. K. (2021). The International Society for the Study of Vulvovaginal Disease
Vaginal Wet Mount Microscopy Guidelines: How to Perform, Applications, and
Interpretation. Journal of Lower Genital Tract Disease, 25(2), 172–180.
https://doi.org/10.1097/lgt.0000000000000595
