Patient Name: Applejack Apple

Chief Complaint: Vaginal discomfort and itching

History of Present Illness (HPI):
Applejack, a 28-year-old mare, presents with a three-week history of discomfort in her genital area. She describes the pain as a constant dull ache, accompanied by swelling and intense itchiness. The pain worsens during urination, described as a burning sensation, with increased urgency. Additionally, she reports noticing a worsening odor, characterized as sour and rotten. The symptoms have been bothersome and impacting her daily activities, particularly her work on the farm. Applejack denies any recent sexual activity or changes in hygiene practices apart from her standard practices, though produced a positive pregnancy test result when in the office. Notably, she mentions that she last saw a gynecologist for a check-up approximately six or seven years ago with no additional care in the interim.

Symptoms have been persistent for the past three weeks, worsening gradually.
Intensity: Applejack rates the pain as moderate to severe, interfering with her daily activities. She experiences the symptoms continuously, with no relief. The symptoms have significantly impacted her ability to work on the farm and engage in daily activities. The patient was found to be pregnant.

Risk Factors:
- Occupation: Applejack works on a farm, engaging in physically demanding activities.
- Sexual History: No recent sexual activity reported.
- Hygiene Practices: No recent changes reported.

Physical Examination:
- Vital Signs:
- Blood Pressure: 120/80 mmHg
- Heart Rate: 80 bpm
- Respiratory Rate: 16 breaths/min
- Temperature: 98.6°F (37°C)
- General: Applejack appears uncomfortable but in no acute distress.
- Genitalia:
- External examination reveals redness, swelling, and tenderness of the labia.
- No obvious lesions or masses noted.
- Pelvic Examination:
- Speculum examination reveals inflammation and tenderness of the cervix and vaginal walls.
- Bartholin's glands appear swollen. Collection of discharge observed.

Assessment:
1. Genital area pain, swelling, and itchiness with dysuria and increased urinary urgency, suggestive of:
- Possible urinary tract infection
- Vulvovaginal bacteriosis
- Bartholin's cyst
2. Worsening odor, suggestive of:
- Possible bacterial vaginosis

Plan:
1. Laboratory Testing:
- Urinalysis and urine culture to evaluate for urinary tract infection.
- Vaginal swab for Gram stain and culture to assess for bacterial vaginosis and candidiasis.
2. Treatment:
- Initiate empiric treatment with oral antibiotics for suspected urinary tract infection.
- Topical antibiotic cream for suspected vulvovaginal bacteriosis.
- Warm compresses for Bartholin's cyst.
- Metronidazole gel or oral metronidazole for bacterial vaginosis if confirmed.
3. Patient Education:
- Emphasize the importance of hygiene and regular gynecological check-ups.
- Educate on proper genital hygiene practices to prevent recurrence.
4. Referral:
- Refer to a gynecologist for further evaluation and management if symptoms persist or worsen.
5. Follow-up:
- Schedule a follow-up appointment in one week to assess response to treatment and review laboratory results.
- Encourage Applejack to seek prompt medical attention if symptoms worsen or new concerns arise before the follow-up appointment.

Signed,
Dr. Anon, MD

Author's Note

The note was included in this story since I thought it would be cool to add a more 'tangible' element associated with Applejack's care, which serves as a vital part of the work of a gynecologist (such notes are often written by medical students, like myself, during internships/rotations).