The Gynecologic Visit

How to take a gynecologic history, decide which parts of the examination a given complaint actually requires, choose the test that answers the question, and write the note.

Two kinds of visit

Every gynecologic encounter is one of two things, or occasionally both, and deciding which one you are in front of shapes everything that follows — how broad the history is, how much of the examination you perform, and what the plan looks like.

Annual / preventive	Problem-focused
Preventive care and screening	Evaluate a specific complaint
Reproductive and sexual health	Focused history
Menstrual health	Targeted examination
Contraceptive and reproductive goals	Appropriate diagnostic testing
Identify new concerns	Diagnosis and management

The presentations that bring a patient in are a short list: preventive care and screening, abnormal vaginal bleeding, pelvic pain, vaginal discharge or vulvar symptoms, menstrual concerns, contraceptive or pregnancy concerns, breast complaints, and menopausal or sexual health concerns. Sort the visit early, because a woman who booked an annual and mentions six weeks of intermenstrual bleeding is now having both visits at once.

⭐ Not every gynecologic visit requires every component of a pelvic examination. The external, speculum, bimanual and rectovaginal examinations are separate decisions, each justified by the history. Performing all four reflexively is not thoroughness; it is an unnecessary examination.

The gynecologic history: start here

The opening of a gynecologic history is almost formulaic, and that is a strength — the same handful of elements orient you before the complaint is even developed.

Age and gravida/para, the two facts that reframe every symptom that follows.
LMP and menstrual history — a date, not "a couple weeks ago."
Pregnancy possibility, asked of every reproductive-age patient at every visit.
Sexual history, contraception, relevant obstetric and gynecologic history, and current gynecologic symptoms.

Those elements assemble directly into the first sentence of the note: "28-year-old G2P2002 female whose LMP was 8/20/26 presents ..." If you can write that sentence, you have the skeleton of the history.

Gravida and para

G = gravida = the number of pregnancies, regardless of how any of them ended. It includes the current pregnancy if she is pregnant now, and a multiple gestation — twins, triplets — is still one pregnancy.

P = para = the number of pregnancies that reached ≥20 weeks of gestation. Parity counts pregnancies, not babies, and the threshold is gestational age at delivery, not whether the infant survived.

Scenario	G/P
Never pregnant	G0P0
Two pregnancies, one reached ≥20 weeks	G2P1
One pregnancy, delivered twins	G1P1, not G1P2
Two pregnancies, both miscarried before 20 weeks	G2P0

⭐ The two traps in parity: twins are one pregnancy and one para, and a loss before 20 weeks adds to gravida but never to para. A 19-week loss and a 20-week loss are one week and one whole number apart.

GTPAL

G/P alone tells you how many pregnancies and how many got past 20 weeks. GTPAL tells you what happened to them. It is written G#P#### — gravida, then four digits after the P.

T = Term → deliveries at ≥37 weeks.
P = Preterm → deliveries from 20 weeks to <37 weeks.
A = Abortion → pregnancies ending before 20 weeks, including both spontaneous abortion (miscarriage) and induced abortion.
L = Living → the number of living children — the only digit that counts babies rather than pregnancies.

The first three digits (T, P, A) count completed pregnancies and sum to G — unless she is pregnant right now, because the current pregnancy counts in G but has not yet landed in T, P or A. L counts people and breaks the pattern the other way: a twin delivery contributes 1 to T or P but 2 to L.

G1P1002	G3P2012
G1 = 1 pregnancy	G3 = 3 pregnancies
T1 = 1 term pregnancy	T2 = 2 term
P0 = 0 preterm pregnancies	P0 = 0 preterm
A0 = 0 abortions	A1 = 1 abortion/loss
L2 = 2 living children	L2 = 2 living children

Read that first example critically. G1P1002 is given as one pregnancy, one term delivery, no preterm, no losses — and two living children. The arithmetic does not work for a single term singleton: one term pregnancy producing one baby gives L1. L2 follows only if that term pregnancy delivered twins, which the example does not state. Learn the digits as defined, but when you build a GTPAL from a narrative, make L match the children the narrative actually describes.

A worked GTPAL problem

A woman has been pregnant three times. One was a full-term singleton. One was triplets delivered at 32 weeks. One was a miscarriage (spontaneous abortion) at 16 weeks. Document her in GP format and in GTPAL format.

GP format: G3P2

G3 = 3 total pregnancies.
P2 = 2 pregnancies reached ≥20 weeks — the term singleton = 1 and the preterm triplets = 1 (the triplets are one pregnancy, not three).
The 16-week miscarriage does not count toward parity, because it ended before 20 weeks.

GTPAL format: G3P1114

G3 = 3 pregnancies.
T1 = 1 term pregnancy.
P1 = 1 preterm pregnancy at 32 weeks.
A1 = 1 miscarriage at 16 weeks.
L4 = 4 living children: 1 singleton + 3 triplets.

Notice where the arithmetic changes gear: T + P + A = 1 + 1 + 1 = 3 = G, the check that every pregnancy is accounted for, but L = 4, larger than G, because one pregnancy produced three children. Work any narrative the same way — count pregnancies for G, sort each by gestational age at its end (≥37 → T, 20 to <37 → P, <20 → A), then count heads for L, and confirm T + P + A = G — adding one to G for a current pregnancy that has not yet ended — before writing it down.

Menstrual, sexual and contraceptive history

Menstrual history: LMP, age at menarche, cycle frequency and regularity, duration of bleeding, flow or amount, dysmenorrhea, intermenstrual bleeding, postcoital bleeding, and menopause status when applicable. A change in menstrual pattern is often the diagnostic clue, so ask what is different from her own baseline rather than whether her cycles are "normal."

Sexual history: take it privately, routinely and nonjudgmentally, asked of everyone so no one is singled out. Cover whether she is currently sexually active, the number and gender of partners, sexual practices when clinically relevant, condom or barrier use, STI history, exposure and testing, dyspareunia or other sexual concerns, and safety or coercion concerns when appropriate. Avoid assumptions about partners, practices or pregnancy risk; the assumption is what makes you miss the exposure.

Contraceptive and reproductive history: current method, satisfaction with it, correct and consistent use, adverse effects, contraindications and risk factors, desire for pregnancy, future pregnancy plans, and infertility when relevant. Running underneath all of it: could this patient be pregnant?

Past gynecologic and family history

Past gynecologic history: prior abnormal Pap or HPV result, STIs or PID, recurrent vaginitis, endometriosis, fibroids, ovarian cysts, infertility, and prior gynecologic malignancy. Then prior procedures and surgeries — colposcopy, LEEP, D&C, endometrial biopsy, sterilization, hysterectomy, oophorectomy — because a past procedure both explains findings and changes what screening still applies.

Family history with a gynecologic focus: breast, ovarian, endometrial and colon cancer, plus the details that make it meaningful — age at diagnosis, multiple affected relatives, and any known hereditary cancer syndrome or genetic mutation. This is not box-checking: family history may change screening and trigger genetic risk assessment, so the same patient with the same symptoms gets a different plan depending on the answer.

Review of systems and life stage

GYN / GU	Breast
Pelvic or abdominal pain	Mass or lump
Abnormal vaginal bleeding	Nipple discharge
Vaginal discharge or odor	Nipple inversion
Vulvar itching, burning, lesions	Skin changes
Dyspareunia	Dimpling or retraction
Pelvic pressure or bulge
Dysuria, frequency, urgency, incontinence

Life stage changes the questions. In the reproductive years, ask about menstrual pattern, sexual health, contraception, pregnancy intentions and STI risk. In perimenopause and after menopause, ask about menstrual changes, vasomotor symptoms, contraceptive needs during perimenopause (fertility falls but does not vanish), postmenopausal bleeding, vulvovaginal and urinary symptoms, and sexual function.

Preparing the patient

Explain why the examination is recommended and describe the general steps before she undresses.
Obtain permission to proceed.
Provide privacy for undressing, and use appropriate gowning and draping.
Offer and use a chaperone per policy.
Ask the patient to empty her bladder.
Show unfamiliar equipment if it helps.
Position comfortably, use appropriately sized equipment, and warm the speculum when possible.

The goal of all of it is patient comfort, dignity, safety and cooperation — and cooperation is not a courtesy, it is what makes the examination technically adequate.

Communicating during the examination

Explain each step before you perform it, and tell her what she may feel — touch, pressure, mild discomfort.
Avoid unexpected or sudden movements.
Maintain eye contact when possible, and monitor facial expression and body language as well as what she says.
Ask for verbal feedback and encourage her to report discomfort.
Remind her she may ask you to pause or stop, and maintain a professional demeanor throughout.

⭐ Significant pain is not expected and should prompt reassessment. Pain during a pelvic examination is a finding, not something to talk a patient through — stop, reconsider technique and equipment size, and reconsider the differential.

Patient-centered and trauma-informed care

Do not assume prior pelvic examination experience — ask.
Ask permission before major steps, not once at the beginning.
Give the patient as much control as possible, and explain positioning and equipment.
Use neutral, anatomically appropriate language.
Avoid judgment regarding sexual activity, partners, contraception or pregnancy history.
Modify or defer the examination when clinically appropriate — a deferred examination with a plan is a legitimate clinical decision.
Stop if the patient withdraws consent. Consent is continuous and can be withdrawn mid-examination.

A technically correct examination must also be respectful, patient-centered and clinically necessary. All three, or it is not a good examination.

The physical examination: overview

The full examination runs: general, thyroid/neck, breast, abdomen, external genital, speculum, bimanual, and rectal/rectovaginal when indicated. Which of those you actually perform is decided upstream: the history determines what examination is necessary.

Breast — inspection	Breast — palpation
Symmetry	Systematic examination of breast tissue
Skin changes	Masses
Dimpling or retraction	Tenderness
Nipple changes	Nipple and areolar area
	Axillary and supraclavicular nodes

Abdominal examination with a gynecologic focus: distention, surgical scars, tenderness, guarding or rebound, a palpable mass, and suprapubic tenderness or fullness. Interpret findings across the whole plausible list — uterine, adnexal, bladder, pregnancy-related and non-gynecologic causes. A right lower quadrant that hurts is not automatically an ovary.

The pelvic examination: external and speculum

The sequence is fixed: 1) external, 2) speculum, 3) bimanual, 4) rectal/rectovaginal if indicated.

External examination. Inspect the mons pubis, labia majora and minora, clitoris, urethral meatus, introitus and perineum. Look for erythema, discharge, lesions or ulcers, masses, swelling, atrophy, trauma and skin changes. Palpate any abnormality, and palpate the Bartholin glands when indicated: they sit at 4 o'clock and 8 o'clock and are a common site of cysts and abscesses, so a unilateral tender swelling in that position has a name before you have done anything else.

Speculum — vagina	Speculum — cervix
Mucosa and rugae	Color
Discharge	Lesions
Blood	Discharge
Lesions	Bleeding / friability
Atrophy	Cervical os

The purpose of the speculum examination is simply to visualize the vagina and cervix — and to collect specimens: Pap/HPV, STI testing or other samples when indicated. A Pap is collected by swirling or rotating the sampling device about 10 times.

⭐ Collect vaginal and cervical specimens during the speculum examination, before the bimanual. Lubricant and manipulation contaminate what you are about to look at — collect the wet mount, the pH sample and the cytology while the speculum is still in, because you cannot go back for them.

The bimanual examination

Technique: insert one or two lubricated, gloved fingers of one hand into the vagina and press on the lower abdomen with the other hand, trapping the pelvic organs between them. The purpose is to feel the size, shape and position of the uterus and ovaries; it also checks the vagina, cervix, fallopian tubes and rectum.

Cervix / uterus	Adnexa / bladder
Cervical position and mobility	Adnexal mass or fullness
Cervical motion tenderness	Adnexal tenderness
Uterine size	Bladder tenderness when clinically relevant
Position and contour
Mobility and tenderness

Interpreting the findings:

Finding	Consider
Cervical motion tenderness	PID
Adnexal tenderness or mass	Ovarian or adnexal pathology
Enlarged uterus	Pregnancy, leiomyoma, adenomyosis
Irregular uterine contour	Leiomyomas

⭐ Bimanual findings guide the differential; they usually do not establish the final diagnosis alone. An enlarged uterus is a reason to order a pregnancy test and an ultrasound, not a reason to write "fibroids" in the assessment.

Rectovaginal and problem-focused examination

The rectal or rectovaginal examination is not routinely necessary for every patient. Consider it for rectal symptoms, posterior pelvic pathology, selected pelvic masses, suspected endometriosis (uterosacral nodularity), and other specific clinical indications. The rule for whether to do it: perform it when the findings are expected to change evaluation or management.

The same logic scales to the whole problem-focused examination — complaint drives focused examination:

Complaint	Examination
Vaginal discharge or vulvar symptoms	External + speculum ± bimanual
Pelvic pain	Abdomen + pelvic examination
Abnormal bleeding	Abdomen + external/speculum ± bimanual
Breast complaint	Targeted breast examination + relevant lymph nodes; additional examination guided by the history

In-office diagnostics

Pregnancy / urinary	Infectious / cervical
Urine pregnancy test	CT/NG NAAT
Serum β-hCG when indicated	Vaginitis testing: pH, wet mount, KOH
Urinalysis	Cultures when indicated (HSV)
Urine culture	Cervical cytology ± HPV testing

CT/NG testing. The NAAT (nucleic acid amplification test) is the preferred test for chlamydia and gonorrhea. It detects genetic material (DNA/RNA) from the organism and is highly sensitive and specific. Acceptable samples are a vaginal or cervical swab or urine, with rectal and pharyngeal testing based on exposure — so ask about sites of exposure or you will test the wrong one.

Culture grows the organism in the laboratory. It is not routinely needed for uncomplicated CT/NG diagnosis. It matters most for gonorrhea when treatment failure or antibiotic resistance is suspected, because culture is what allows antimicrobial susceptibility testing — a NAAT tells you the organism is there but nothing about what will kill it.

Vaginal pH, wet mount and KOH

Vaginal pH helps differentiate the common causes of vaginitis before you ever look at a slide.

pH	Interpretation
3.8–4.5	Normal
Usually normal (≤4.5)	Candida
Typically >4.5	Bacterial vaginosis
Typically >4.5	Trichomoniasis

Wet prep is microscopic evaluation of vaginal discharge: vaginal fluid is placed on a slide with saline and KOH and examined under a microscope.

Saline shows clue cells → bacterial vaginosis and motile trichomonads → trichomoniasis (trichomoniasis can also be diagnosed by NAAT). Saline also lets you assess WBCs and other findings suggesting inflammation.
KOH is potassium hydroxide. A small amount of discharge is mixed with it; the KOH dissolves and degrades cellular material, making yeast elements easier to see. Candida shows budding yeast and/or pseudohyphae.
Adding KOH can also produce a fishy amine odor — the "whiff test" — in bacterial vaginosis.

⭐ Two slides, four answers: saline wet mount → clue cells and motile trichomonads; KOH prep → yeast plus the whiff test for BV. Anchor them with the pH: a normal pH with pseudohyphae is candida; a pH above 4.5 with clue cells and a positive whiff is BV.

HSV, Pap and HPV testing

HSV testing detects herpes simplex virus (HSV-1 or HSV-2) from an active genital lesion. The sample is a swab from the base of a vesicle, ulcer or other active lesion — unroof the vesicle and swab the base, not the intact dome. HSV NAAT/PCR is the preferred test because of its greater sensitivity; viral culture attempts to grow the virus from the specimen and is less sensitive. For either method, sensitivity decreases as lesions begin to heal, so a negative result from a crusted lesion several days old does not rule herpes out.

Pap / cervical cytology	HPV testing
Evaluates cervical cells	Detects high-risk HPV
Screens for precancerous changes	An abnormal screening result may lead to surveillance, colposcopy or biopsy

⭐ Screening is not diagnosis. A Pap or HPV result stratifies risk and decides the next step; the diagnosis comes from tissue — colposcopy with biopsy. Never report a cytology result to a patient as a diagnosis of anything.

Imaging

Transabdominal ultrasound	Transvaginal ultrasound (TVUS)
Broader pelvic view — a wide survey, useful for a large mass or bulky uterus beyond the reach of the vaginal probe	Better visualization of the uterus, endometrium and adnexa — the probe sits closer to the target
Often performed with a full bladder, which displaces bowel and gives an acoustic window	Common for pelvic pain, abnormal bleeding, adnexal mass and early pregnancy evaluation

A transducer passed over the abdomen, or a probe inserted into the vagina, bounces sound waves off internal organs and tissues to make echoes that form a sonogram. Note the opposing bladder instructions: she empties her bladder before a pelvic examination but may need a full bladder for a transabdominal ultrasound. Pelvic ultrasound is first-line imaging for many gynecologic complaints — available, radiation-free, and able to answer most of the structural questions the bimanual raised.

Common procedures

Colposcopy — magnified examination of the cervix to identify abnormal areas, usually performed after an abnormal cervical cancer screening result. Biopsy takes a small tissue sample from a suspicious area for pathology, giving the tissue diagnosis. ± ECC (endocervical curettage) samples the endocervical canal when indicated.
Endometrial biopsy (EMB) — office sampling of the endometrium, used to evaluate for endometrial hyperplasia or cancer, particularly with abnormal uterine bleeding. It is diagnostic, not therapeutic.
Hysteroscopy — a camera passed through the cervix into the uterine cavity that directly visualizes polyps, fibroids, adhesions and other abnormalities and allows targeted biopsy or treatment.
D&C (dilation and curettage) — the cervix is dilated and the uterine contents or endometrium scraped. Used for pregnancy loss, selected acute heavy bleeding, or diagnostic evaluation. Major complication: uterine perforation.
Laparoscopy — a camera inserted through small abdominal incisions to visualize the pelvis and abdomen, used for endometriosis, ectopic pregnancy, ovarian cystectomy, pelvic pain and hysterectomy. It allows diagnosis plus treatment in one setting.

Hysterectomy	What is removed
Total	Uterus + cervix
Supracervical / subtotal	Uterus removed; cervix remains
+ bilateral salpingectomy	Uterus + both fallopian tubes
+ BSO (bilateral salpingo-oophorectomy)	Uterus + both tubes + both ovaries
Radical	Uterus, cervix, both ovaries, both fallopian tubes and nearby tissue

One caveat worth carrying forward: what makes a hysterectomy radical is removal of the parametrial tissue and upper vagina alongside the uterus and cervix. Whether the ovaries come out is a separate decision, and they are often preserved in a premenopausal woman.

Surgical approaches: vaginal, laparoscopic/robotic, and abdominal hysterectomy. Note that "total" does not mean everything — it is uterus and cervix, with the ovaries named separately as a BSO — and that a supracervical hysterectomy leaves the cervix behind, so that patient still needs cervical screening.

Documenting the annual visit

The comprehensive note runs in a set order: age + G/P + LMP, then menstrual history, obstetric and gynecologic history, sexual history, contraception and pregnancy intentions, screening history, relevant family history, ROS and physical examination, and finally assessment plus preventive counseling and plan.

Screening history gets date + result whenever they are known: last Pap, last HPV, prior abnormal Pap or HPV, last mammogram, STI screening, and other age- and risk-appropriate screening.

Normal physical examination phrasing, component by component:

Component	Documented as
General	WDWN, NAD, A&O ×3
Breast	No dominant mass, skin changes, nipple retraction or discharge
Abdomen	Soft, NT; no palpable mass
External	Vulva without lesions, erythema or abnormal discharge
Speculum	Vaginal mucosa normal; cervix without lesions or discharge
Bimanual	No CMT; uterus nontender; no palpable adnexal mass or tenderness

⭐ "Pap UTD" is not documentation. Write "Pap 6/2025: NILM; HPV negative" instead. "Up to date" carries no date and no result, so the next clinician cannot tell when the next test is due or whether surveillance is needed — and neither can you in a year.

The problem-focused note, and the two visits compared

Focused SOAP note:

S — chief complaint and HPI, LMP, G/P, relevant menstrual, gynecologic and sexual history, pregnancy possibility, and ROS.
O — vitals, the targeted examination, and point-of-care tests (pH, wet mount, urine pregnancy test).
A — the diagnosis plus a relevant differential.
P — testing, treatment, counseling, and follow-up / return precautions.

Annual gynecologic visit	Problem-focused visit
Preventive	Complaint-driven
Comprehensive history	Focused history
Review screening	Relevant screening
Preventive counseling	Problem-specific counseling
Examination based on preventive and clinical needs	Targeted examination
Broad plan	Focused assessment and plan

Both visit types always require consideration of LMP, pregnancy possibility, relevant sexual history and reproductive history. Those four never drop out, no matter how narrow the complaint.

A simple approach to any gynecologic complaint

1. Could she be pregnant? → LMP, sexual activity, contraception, urine pregnancy test when indicated.
2. Where is the problem? → vulva, vagina, cervix, uterus, adnexa.
3. What is the major symptom? → bleeding, pain, discharge/infection, mass, menstrual/hormonal, or pregnancy-related.
4. What examination is needed? → external, speculum, bimanual, breast, abdominal.
5. What test answers the question? → urine pregnancy test, urinalysis, wet mount, STI testing, Pap/HPV, ultrasound, biopsy.

Questions 1–3 are asked from the history alone; only then do you decide on the examination and the testing.

⭐ History → Exam → Differential → Targeted Testing. The chain runs one way. A test ordered before the differential exists is a test whose result you will not know how to use.

Worked case: the preventive visit

"Annual GYN exam." A 26-year-old G2P2002 woman presents for a routine preventive visit. LMP 8/18/26; menarche age 12; menses every 28–30 days, 4–5 days, moderate with mild cramping; no intermenstrual or postcoital bleeding. Sexually active with one male partner of 3 years (married), on combined oral contraceptives, satisfied with the method, not desiring pregnancy; condoms not used routinely. She denies pelvic pain, dyspareunia, abnormal discharge, vulvar and urinary symptoms, and has no history of STIs or abnormal cervical cancer screening. Both pregnancies were uncomplicated term spontaneous vaginal deliveries. Last screening 2024, normal per patient; HPV vaccination complete. No family history of breast, ovarian, endometrial or colorectal cancer. Medication: norethindrone acetate 1 mg / EE 20 mcg, 1 tablet PO daily. NKDA.

Examination. T 98.4°F (36.9°C), BP 116/72 mm Hg, HR 72/min, RR 14/min, SpO₂ 99% RA, BMI 23.4 kg/m². Breasts symmetric without masses, skin changes, nipple retraction or discharge; no axillary lymphadenopathy. Abdomen soft and nontender. External genitalia without lesions, erythema or abnormal discharge. Speculum: vaginal mucosa pink and moist; cervix without lesions, discharge or friability. Bimanual: uterus normal size, mobile and nontender; no CMT; no adnexal tenderness or masses.

Assessment: routine preventive gynecologic examination; contraceptive surveillance; preventive screening and counseling.

Plan: next Pap due 2027 based on age and risk. STI screening by age and individual risk — deferred today by shared decision making. Continue combined hormonal contraception; she is satisfied and desires pregnancy prevention for 3+ years — Rx norethindrone acetate 1 mg / ethinyl estradiol 20 mcg tablets + ferrous fumarate 75 mg tablets, 1 tablet PO daily as directed, dispense 84 tablets (3 packs), 3 refills. Review breast awareness and age- and risk-appropriate breast cancer screening. Continue general preventive care including BP, BMI, immunizations, tobacco and alcohol use, mental health and safety. Return for routine care or sooner for new symptoms.

Worked case: the problem-focused visit

"Vaginal discharge and itching." A 22-year-old G0P0 woman presents with a 4-day history of increased vaginal discharge and vulvar itching. The discharge is thick, white and clumpy without a strong odor. She has external vulvar burning but denies dysuria, pelvic pain, fever, chills, abnormal bleeding and dyspareunia. LMP 8/14/26, cycles every 30 days, regular, 4–5 days, moderate. Sexually active with a new male partner of 2 months, inconsistent condom use, no other contraception, last intercourse 5 days ago; denies known STI exposure or prior STIs. A similar episode of vulvovaginal candidiasis about 2 years ago; no PID, no abnormal screening, no gynecologic procedures, no diabetes or immunocompromizing condition. She completed a course of amoxicillin-clavulanate about 1 week ago for sinusitis. NKDA.

Examination. T 98.6°F (37.0°C), BP 112/68 mm Hg, HR 74/min, RR 14/min, SpO₂ 99% RA. Abdomen soft and nontender without guarding or rebound. External genitalia: mild vulvar erythema, no ulcerations or vesicles. Speculum: thick white vaginal discharge, vaginal mucosa mildly erythematous; cervix normal without mucopurulent discharge, friability or visible lesions. Bimanual: no CMT, uterus normal size and nontender, no adnexal tenderness or masses.

Diagnostics. Urine pregnancy test negative. Vaginal pH 4.0. Wet mount / KOH preparation: budding yeast and pseudohyphae present, whiff negative; no clue cells or motile trichomonads. CT/NG NAAT obtained because of the discharge and the sexual history.

Assessment: vulvovaginal candidiasis; vaginal discharge.

Plan: treat uncomplicated vulvovaginal candidiasis with appropriate antifungal therapy — fluconazole 150 mg PO × 1 dose. CT/NG pending; notify the patient of results and treat appropriately. Counsel on vulvar hygiene and avoiding unnecessary scented or irritating products. Discuss condom use and STI prevention. Return for persistent or worsening symptoms, pelvic pain, fever, or failure to improve.

Pearl: Read the second case backward and every step justifies itself — the recent antibiotic course explains the yeast, the pH of 4.0 and negative whiff argue strongly against BV and trichomoniasis without waiting for anything — though microscopy is insensitive for trichomonads, so a NAAT is what settles that question when suspicion is high — the normal-appearing cervix argues against cervicitis, and the new partner with inconsistent condom use is why the NAAT was still sent. The examination narrowed the differential; the point-of-care tests closed it.