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Abstract: Ms. Zhang described herself as having a marked increase in vaginal discharge in the past 3 days, which was thin and frothy, yellow in color, and odorous, as well as symptoms of frequent urination, urgency and painful urination. Based on the gynecological internal examination, routine leucorrhea examination and routine urine examination, the initial diagnosis was acute vaginitis. Outpatient was given ornidazole dispersible tablets and levofloxacin hydrochloride capsule orally with metronidazole suppository. After 7 days of treatment, the discomfort was relieved and the discharge was normal.
Basic information】Female, 28 years old
Disease Type】Acute vaginitis
Hospital】Jinan Hospital of Integrative Medicine
Date of consultation】February 2022
Treatment plan】Medication (Ornidazole dispersible tablets, Levofloxacin hydrochloride capsule, Metronidazole suppository)
Treatment period】7 days of outpatient treatment
Treatment effect] Normal discharge, disappearance of uncomfortable symptoms, good treatment effect
I. Initial consultation
Recently, due to frequent overtime work, poor body resistance and lack of attention to personal hygiene, the vaginal discharge increased significantly in the past 3 days, with thin, foamy, yellowish and odorous discharge.
Internal gynecological examination revealed that the vaginal discharge was thin, yellowish and odorous. The discharge was taken for routine leucorrhoea examination and routine urine examination. Based on the results of the gynecological examination and laboratory tests, the outpatient physician made a preliminary diagnosis of acute vaginitis and recommended 7 days of systematic drug treatment.
(Results of vaginal secretion examination)
II. Treatment history
After Ms. Zhang visited the gynecological clinic, the outpatient doctor made a preliminary diagnosis of acute vaginitis based on relevant examinations. After detailed medical history, laboratory tests of vaginal secretions and routine urine examination, she was diagnosed with acute trichomoniasis, which is a subtype of acute vaginitis, based on the examination results. After asking for allergy history, she was given oral ornidazole dispersible tablets and levofloxacin hydrochloride capsules, daily outpatient ozone douching, and vaginal metronidazole suppositories every night. Ms. Zhang’s husband was instructed to apply the above antibiotics together with her to avoid cross-infection in the same room after treatment.
Treatment effect
As Ms. Zhang was suffering from acute vaginitis for the first time, she was treated with antibiotics in time, together with ozone douche and vaginal topical medication for 7 days, she reported that her vaginal discharge was normal, no odor, no symptoms of vaginal itching, and her symptoms of frequent, urgent and painful urination had disappeared. Since Ms. Zhang’s treatment was relatively timely and the treatment plan was correctly chosen, the results of the routine examination of the leukorrhea and urine three days after the end of treatment showed that everything was normal and the treatment effect was good, and the patient was very satisfied with the treatment effect.
IV. Notes
Ms. Zhang is happy that her symptoms are relieved after treatment, but she needs to pay attention to the following matters after treatment.
1, pay attention to personal vulva cleanliness and hygiene, wash the vulva every night before going to bed, do not casually rinse the vagina, so as not to destroy the normal vaginal flora, keep the vulva clean and hygienic after intercourse, to avoid cross-infection.
2, usually wear loose, cotton, breathable underwear, diligently change and wash underwear, after washing in direct sunlight, separate from family members for cleaning, diligently change sanitary napkins and pads during menstruation.
3, try to avoid going to public places, such as hotels, public baths, etc., to avoid cross-infection.
4, diet, mainly light diet, do not eat too much spicy food, pay attention to regular work and rest, and actively exercise to improve body resistance, enhance the ability to resist disease.
V. Personal insight
Acute vaginitis is a very common inflammatory disease in gynecology clinics, and it occurs in married, fertile, sexually active women. Once a patient has abnormal vaginal discharge, itchy vagina and vulva, painful intercourse, frequent urination, urgent urination and painful urination, it is important to pay attention to the symptoms and seek treatment in time. Acute vaginitis, like this case, is relatively better treated and can be relieved in about 7 days with medication. However, if the patient is not detected and treated in time, resulting in recurrent vaginitis, the treatment course will be extended accordingly, which will seriously affect work and life in general.