Subjective: Patient presents with complaints consistent with vulvovaginal candidiasis (yeast infection).  She reports vulvar pruritus, burning, and irritation, along with a thick, white, cottage cheese-like vaginal discharge. Symptoms began approximately three days ago and have progressively worsened.  She denies fever, chills, abdominal pain, or dysuria.  She reports recent antibiotic use for a sinus infection.  Patient denies any known allergies.  Past medical history includes hypothyroidism and seasonal allergies.  Gynecological history includes menarche at age 12, regular menses, and gravida 0, para 0.  She is sexually active with one partner and uses condoms inconsistently.

Objective:  On examination, the vulva appears erythematous and edematous with excoriations noted.  Vaginal speculum exam reveals a thick, white, adherent discharge.  The vaginal walls appear erythematous.  No cervical motion tenderness or adnexal masses are palpated.  Wet mount preparation reveals budding yeast and pseudohyphae, confirming the diagnosis of vaginal candidiasis.

Assessment:  Vaginal yeast infection (vulvovaginal candidiasis), likely precipitated by recent antibiotic use.

Plan:  Patient was educated on the diagnosis and treatment of vaginal candidiasis.  She was prescribed fluconazole 150mg oral tablet, single dose.  Patient was advised on preventative measures, including avoiding tight-fitting clothing, maintaining good hygiene practices, and considering probiotic supplementation.  She was also counseled on the importance of consistent condom use to prevent sexually transmitted infections.  Follow-up is recommended if symptoms do not resolve within one week.  ICD-10 code B37.3 (Candidiasis of vulva and vagina) is documented for billing and coding purposes.  Differential diagnoses considered included bacterial vaginosis and trichomoniasis, which were ruled out based on clinical presentation and microscopic examination.