Patient presents with complaints of vaginal discomfort.  Symptoms include vaginal itching, burning, irritation, and dryness.  Onset of symptoms began approximately [duration] ago and is [constantintermittent].  Patient reports [aggravating factors such as intercourse, certain products, etc.] and [alleviating factors such as lubricants, avoidance of irritants, etc.].  Associated symptoms may include dyspareunia, abnormal vaginal discharge, odor, or pelvic pain.  Patient denies fever, chills, or other systemic symptoms.  Past medical history includes [relevant medical history e.g., diabetes, STIs, hormonal changes, menopause, vulvovaginal atrophy, allergies, recent antibiotic use].  Medications include [list current medications].  Physical examination reveals [external genitalia exam findings e.g., erythema, edema, excoriations, lesions, discharge characteristics including color, odor, and consistency].  Speculum examination reveals [vaginal wall and cervix appearance].  Differential diagnoses include vulvovaginitis, yeast infection, bacterial vaginosis, atrophic vaginitis, contact dermatitis, and sexually transmitted infections.  Vaginal pH is [pH value].  Wet mount microscopy results [describe microscopic findings e.g., presence of clue cells, hyphae, trichomonads, WBCs].  KOH whiff test [positive or negative].  Laboratory tests ordered include [list ordered tests e.g., vaginal culture, STI testing].  Assessment:  Vaginal discomfort likely secondary to [presumptive diagnosis].  Plan:  Patient educated on proper hygiene practices, including avoiding irritants.  Prescribed [treatment e.g., antifungal medication, antibiotic therapy, topical estrogen cream, lubricant] and advised to follow up in [duration] for reevaluation.  Patient counseled on signs and symptoms to watch for and instructed to return sooner if symptoms worsen or do not improve.  Coding considerations include [relevant ICD-10 codes for vaginal discomfort, specific etiology, and related symptoms].  Billing codes will reflect the evaluation and management services provided as well as any procedures or laboratory tests performed.