Vaginal Discharge

Question 1

A 24 years old lady presented with history of vagina discharge, of 1 week duration. Take a focused history from her

Answer 1

Grip
BIODATA
Ma, what brings you to the hospital

Question 2

COURSE ANALYSIS (doctor)

Answer 2

How long have you noticed this?
Did it start suddenly or gradually?
What’s the color of the discharge?
What is the consistency of the discharge? Is it cheese like, watery or mucoid?
Any associated smell or odor?
How much is the discharge? How often do you need to change underpants or sanitary pads?
Any history of itching , painful urination, or pain with coitus.

Question 3

CAUSES

Answer 3

Any history of fever? Vagina pain or sore?
Is the discharge related to your menstrual cycle or sexual excitement?
Are you sexually active? Do you have multiple sexual partners? Do you use protection?
Do you douche ? Or use cream/ soap for vagina cleansing?
Any history of instrumentation of foreign body insertion?
Have you noticed any vagina bleeding or spotting with associated to weight loss?
Any history of prolonged use of antibiotics, steroids, or contraceptives?
Do you know your HIV status?

Question 4

COMPLICATIONS

Answer 4

Any history of fever with associated lower abdominal pain

Any history of painful intercourse with post coital bleeding

Have you noticed decrease in your sec drive?

Question 5

CARE SO FAR

Answer 5

What have you done so far for this condition
- Have you visited any prayer house, pharmacy or hospital?
- Have you taken any local concoction or were you given any medications?
- Have you done any investigations? Pelvic ultrasound, ,

Question 6

GYNECOLOGICAL HISTORY

Answer 6

• At what age did you see your first menstrual period
• At what age did you stop having your periods?
• How many days do you bleed for?
• Do you see your period every month?
• Do you know the length of your cycle?
• Do you have menstrual cramps and excessive bleeding ?
• How many pads do you usually use
• Do you have painful sexual intercourse?
• Have you had any abortions or miscarriages in the past?
• Are you aware of contraceptives? Do you use any?
• Are you aware of pap smear? Have you done one?

Question 7

PAST MEDICAL HISTORY

Answer 7

• Have you had similar conditions in the past?
• Have you had any history of chronic illnesses like hypertension, epilepsy, asthma, diabetes, sickle cell disease? (HEADS)
• Have you had any surgery, blood transfusion or hospitalization in the past? If yes…why?

Question 8

DRUG HISTORY

Answer 8

Drug history
- Are you on any long-term medication?
- Are you on any current medications?
- Do you have any drug allergies?

Question 9

FAMILY AND SOCIAL HISTORY

Answer 9

Family history
Any history of similar conditions in the family history of hypertension, epilepsy, asthma, diabetes or sickle cell disease in the family?

Social history
- Do you smoke?
- Do you drink alcohol?
- Do you have multiple sexual partners?

Question 10

REVIEW OF SYSTEM

Answer 10

Ma, just to be sure I didn’t miss any symptoms, I would like you to say yes or no to the following questions
- CNS – any headache, blurry vision, seizures
- Endocrine – any neck swelling, excessive weight loss or weight gain
- Respiratory – any snoring, noisy breathing, fast breathing
- CVS – cough, chest pain, palpitations
- Digestive – any abdominal pain, nausea or vomiting
- Genitourinary – increased urination, blood in urine, discharge form private part
- Musculoskeletal – joint pain, joint stiffness, difficulty walking
THANK YOU, EXAMINER!!!