Subjective: Patient presents with complaints consistent with vulvovaginal candidiasis (yeast infection).  She reports pruritus, vulvar burning, and thick, white, cottage cheese-like vaginal discharge.  Symptoms began approximately three days ago and have progressively worsened.  She denies fever, chills, abdominal pain, or abnormal vaginal bleeding.  She reports recent antibiotic use for a sinus infection.  Past medical history includes recurrent yeast infections.  Patient denies known allergies.  Gynecological history is unremarkable except for the aforementioned recurrent yeast infections.  Social history is non-contributory.

Objective:  Vulva appears erythematous and edematous with excoriations noted.  Speculum examination reveals thick, white, adherent discharge.  Vaginal pH is 4.0.  Wet mount microscopy demonstrates budding yeast and pseudohyphae, confirming the diagnosis of vaginal candidiasis.  No cervical motion tenderness or adnexal masses are noted.

Assessment: Vaginal Candida (yeast infection) secondary to recent antibiotic use.  Differential diagnoses considered included bacterial vaginosis and trichomoniasis, but these were ruled out based on clinical presentation and microscopic findings.

Plan:  Patient was prescribed Fluconazole 150mg PO single dose.  Patient education provided regarding the importance of completing the prescribed medication, avoiding douching, and wearing cotton underwear.  Discussed potential triggers for recurrent yeast infections, including antibiotic use, diabetes, and hormonal changes.  Patient advised to return if symptoms do not improve within one week or if new symptoms develop.  Follow-up scheduled in two weeks to assess treatment response and discuss preventative measures for future infections.  ICD-10 code B37.3 (candidal vulvovaginitis) assigned.