Vaginal discharge — structured oral station (12 minutes)

Opening prompt — "How do you discriminate between the common causes of vaginal discharge at the bedside?"

Model response — odour, itch, inflammation, then pH: ^[1][3]

• "Three cheap tests do most of the work: vaginal pH from the lateral wall, a whiff test with 10% KOH, and a saline plus KOH wet mount."
• "Fishy odour, a pH over 4.5, clue cells and NO inflammation is bacterial vaginosis. Pruritus, curds and a NORMAL pH is candidiasis. A purulent, inflamed discharge with parabasal cells is aerobic vaginitis."
• "pH is the fastest single discriminator: over 4.5 points to BV, AV or trichomoniasis; normal points to candidiasis."^[1][3]

Probe 1 — "Her pH is 5.0, the whiff is positive and there are clue cells. What is the diagnosis and the diagnostic standard?"

• "Bacterial vaginosis, by Amsel criteria — at least three of homogeneous discharge, clue cells, pH over 4.5, and a positive whiff; she has all four."
• "The reference-standard laboratory confirmation is the Nugent Gram-stain score: 0 to 3 normal, 4 to 6 intermediate, 7 to 10 BV."^[1][2]

Probe 2 — "What is your treatment?"

• "CDC 2021: metronidazole 500 mg orally twice daily for 7 days, or metronidazole 0.75% gel intravaginally once daily for 5 days, or clindamycin 2% cream intravaginally at bedtime for 7 days."
• "I counsel her that clindamycin cream is oil-based and weakens latex condoms for 5 days, that routine male-partner treatment does not prevent recurrence, and that she should avoid douching."^[1]

Probe 3 — "She returns three months later with intense pruritus, curds and a normal pH. Now what?"

• "Uncomplicated vulvovaginal candidiasis — fluconazole 150 mg orally as a single dose, or a short-course intravaginal azole."
• "If it were recurrent (three or more episodes in a year), I would induce remission with fluconazole every third day for three doses, then maintenance fluconazole weekly for six months."^[1][4]

Probe 4 — "She is embarrassed and worried she has an STI. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[1]

• Move to her eye level, use her name, acknowledge the concern: "BV and candidiasis are not sexually transmitted infections — they are changes in your own vaginal flora. We will treat the cause, and I will also offer you a routine STI screen so you leave with a complete answer."
• Offer a clear plan, a named contact for between visits, and a safety-net for persistent or recurrent symptoms.^[1]

Probe 5 — "What if the discharge were purulent and inflamed with parabasal cells instead?"

• "That is aerobic vaginitis — Donders' entity, distinct from BV. The organisms are aerobic (Group B strep, E. coli, S. aureus), there is true inflammation, and metronidazole does NOT treat it."
• "I would manage it with a local antiseptic or antibiotic, restore the lactobacilli, and consider topical oestrogen if there is an atrophic component."^[3]