Seen by Dr. Sarah Patel (Clinical practitioner role) 8 months ago
Patient was seen with mum. Patient reported vulval/vaginal itching with burning sensation when she pees ongoing for 4days.
On examination: Vitals are stable. External inspection of vulval area with consent from mum and patient- vulval rednessand little whitish discharge noted, no evidence of ulceration.
Urinalysis; Leucocytes 1+, negative nitrates
Impression: Vulvovaginal candidiasis, r/o UTI
Plan: Send urine for culture, treat for thrush (Candida) withtopical clotrimazole 1% cream applied 2–3 times a day to theanogenital area affected for 7 days. Worsening advice given.
Telephone consultation with Dr. Emily Robertson 3 months ago
Mum called, reports that patient has symptoms of vaginal itching and redness down below. No urinary symptoms. She says symptoms are similar to what she had 5 months ago and requesting to be prescribed clotrimazole cream as it helped.
Plan: Topical clotrimazole 2% cream TDS for 7 days prescribed;no examination performed. Worsening advice given Grand-Mum (Katerina Kovalenko) on call to discuss concerns.
Urine culture
Microscopy:
Culture:
Sensitivity Testing: Not applicable (No organisms isolated).