razhan •Follow Internal Medicine Resident ### Case: 4 months Vaginal discharge 30 years old female presented with vaginal discharge for 4 months. the discharge is watery, milky, odorless discharge during the whole month associated with dysuria, mild to moderate burning sensation during sexual intercourse, unilateral left sided suprapubic pain and back pain on the same side, no vaginal itching or edema or redness, no fever, no vomiting. The gynecologist prescribed these treatments during these 4 months: fluconazole, ectrose, clotrimazole, miconazole, sodium bicarbonate vaginal douche, metronidazole. Once she discontinued the antifungal treatment, the discharge reappeared. - Single sexual partner - No contraceptive used Investigations were unremarkable: - CBC normal - Abdominal US normal - Vaginal swab culture was negative - GUE showed UTI and received treatment with nitrofurantoin. Now the gynecologist wants to start with trimethoprim for one month. She came to me worrying about not being pregnant despite trying for 5 months to conceive. **What’s the most likely diagnosis?** --- ### Previous Cases #### Case 1: 21-year-old female with type 1 diabetes A 21-year-old female college student with type 1 diabetes mellitus comes to the physician because of a two-week history of vaginal itching and burning. She also noticed white vaginal discharge despite cleaning her genital area daily. She is worried that she might have contracted a sexually transmitted infection after meeting her new boyfriend approximately one month ago. She swims for the college swimming team. She had an intrauterine device implanted 3 months ago and does not use barrier protection. She smokes one pack of cigarettes per day and does not drink alcohol. Speculum examination shows an erythematous vagina covered in copious white discharge. Her vaginal pH is 4.4 and the microscopic image of a KOH preparation shows multiple pseudohyphae. **Which of the following is the greatest predisposing factor for this patient’s condition?** A. Smoking history B. Regular use of swimming pools C. Unprotected sexual intercourse D. Intrauterine device E. Diabetes mellitus #### Case 2: Previous similar complaint A previously presented case came to me at a rural area for the same complaint. This time she described her discharge like a menstrual cycle of watery discharge, associated with lower back pain and dysuria. She has to change pads every day due to the discharge. It's odorless and non-sticky. She took Bactrim for 1 week and metronidazole for 14 days; it eased her condition last month, but after ending her cycle this month, the condition became worse. Blood investigations and vaginal swab culture showed no growth and no abnormality. **What do you think the diagnosis is and what are the next steps to end the discharge?** #### Case 3: Clinical scenario in early twenties Clinical scenario - female in early twenties, G.O., LMP - a month ago, 24-28 day cycle, typically bleeds 3-4 days, has painful periods, first sexual intercourse 1 year ago, one partner unprotected sex, presents with yellowish vaginal discharge. Upon further questioning, there is pain with sex. She received a pelvic exam that was interpreted as “vaginal discharge” treated with broad-spectrum antibiotics, and vaginal culture including G/C test pending; UA in office showed 4+ leukocytes. Now returns two days later with heavy bleeding and pain, as she indicated that “she is not due for a normal menses for seven more days.” Pelvic exam showed bloody fluid in the vaginal vault coming from cervical os— bHCG-negative. Wet prep in office - 4+ purulent and bloody debris; and numerous glycogenated cells versus koilocytic cells. She could not afford to have a Pap smear sample sent to the lab for interpretation and asked if this could be done after the bleeding stops. **Who would you advise and manage this patient?** #### Case 4: 21-year-old F presenting with vaginal itching Can you guess what's under my microscope? 21yo F presents with vaginal itching, discharge, and "uncomfortable" intercourse for 4 days. Wet mount from vaginal discharge shown here. **Diagnosis and treatment?** #### Case 5: 52-year-old man with chest pain #### Case 6: 28-year-old woman with pruritus #### Case 7: 4-month-old infant with skin lesions #### Case 8: Cardiac event in late teens