What is included in the clinical history to evaluate vaginitis?

Updated: Dec 04, 2018
  • Author: Hetal B Gor, MD, FACOG; Chief Editor: Michel E Rivlin, MD  more...
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Answer

A carefully documented history is vital for establishing the diagnosis. [21] Adults and children must be questioned regarding specific aspects of the symptoms of vaginitis. Essential information to obtain during the history includes the onset of symptoms, previous occurrences, associated abdominal pain, trauma, and urinary or bowel symptoms.

Vaginal bleeding in prepubertal females is always abnormal and warrants a full investigation. In adults, as noted (see Etiology), the most common conditions resulting in symptoms of vaginitis include vaginal candidiasis, trichomoniasis, and bacterial vaginosis; accordingly, particular attention should be paid to symptoms suggesting these possible causes.

Patients with vaginitis almost always present with a chief complaint of abnormal vaginal discharge. Ascertain the following attributes of the discharge:

  • Quantity

  • Duration

  • Color

  • Consistency

  • Odor

Obtain a history of the following:

  • Previous similar episodes

  • Sexually transmitted infection

  • Sexual activities

  • Birth control method

  • Last menstrual period

  • Douching practice

  • Use of personal hygiene products

  • Antibiotic use

  • General medical history

  • Systemic symptoms (eg, lower abdominal pain, fever, chills, nausea, and vomiting)


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