You are seeing Stacey Holland, a 23 year old female, for vaginal discharge. Please take a focused history for her complaint.
History
- Onset and duration of vaginal discharge
- Appearance of discharge
- Association with menstruation
- Presence of blood
- Itching
- Dyspareunia
- Pain on defecation
- Fever
- Nausea/vomiting
- Perineal/vaginal sores
- Abdominal pain/discomfort
- Rash or other lesions
- Swollen joints
- Vision changes
- Dysuria
- Hematuria
- Increased frequency of urine
- Last menstrual period
- Menorrhagia
- Dysmenorrhea
- Regularity of menstruation
- Past abdominal surgery
- Pregnancy history
- Current and past sexual history, including partners, method of intercourse, and contraception
- Smoking and alcohol history
- Medications – especially oral contraceptive pill
- Allergies
- Personal history of sexually transmitted infections and related investigations/treatment
- Last Pap smear and result
Case 2 – Vaginal Discharge