Let’s think through this. A yellow vaginal discharge in a 6-year-old is quite different from the same finding in a 16-year-old. Here’s how I’d approach it as a nurse practitioner:

Key Points in History and Physical Examination (6-Year-Old)

History:

• Detailed Description of Discharge:
  • Onset, duration, frequency
  • Amount, color, consistency, odor
  • Associated symptoms: itching, burning, pain, dysuria, vulvar redness or swelling
• Hygiene Practices:
  • How does she wipe after using the toilet? (Front to back is important)
  • Type of soap used for bathing
  • Frequency of bathing
  • Tight-fitting clothing or synthetic underwear
• Trauma or Foreign Body:
  • Any possibility of accidental injury to the genital area?
  • Has she inserted anything into her vagina? (This can be difficult to elicit but is important to consider)
• Sexual Abuse History:
  • While being sensitive and age-appropriately, inquire about any possibility of unwanted touch or exposure. This is a crucial part of the differential in a young child.
• Recent Illnesses:
  • Any recent streptococcal infections (can cause vulvovaginitis)?
  • Any antibiotic use (can disrupt normal flora)?
• Family History:
  • Any family history of similar issues?
• Bowel Habits:
  • Any fecal soiling or constipation?

Physical Examination:

• General Appearance: Note any signs of distress or discomfort.
• Abdominal Examination: Palpate for any masses or tenderness.
• External Genital Examination:
  • Careful inspection of the vulva and perineum for:
    • Erythema (redness)
    • Edema (swelling)
    • Discharge (note color, amount, and odor)
    • Lesions, bruising, or signs of trauma
    • Presence of a foreign body (may be visible or palpable)
  • Avoid internal examination unless there is a strong suspicion of a foreign body or abuse, and then it should be done by an experienced provider, often under sedation.
• Perianal Examination: Check for redness, irritation, or signs of pinworm infection (scotch tape test might be indicated).
• Lymph Node Examination: Palpate inguinal lymph nodes for enlargement or tenderness.

Approach for a Sexually Active 16-Year-Old

The differential diagnosis shifts significantly with sexual activity.

History:

• Detailed Description of Discharge: Same as above.
• Sexual History:
  • Age of sexual debut
  • Number of partners (current and lifetime)
  • Types of sexual activity (vaginal, oral, anal)
  • Barrier protection use (condoms) – consistency and correct use
  • History of sexually transmitted infections (STIs) in the patient or their partners
  • Symptoms in current or previous partners
• Menstrual History:
  • Last menstrual period
  • Regularity of cycles
  • Any intermenstrual bleeding or postcoital bleeding
• Contraceptive Use: Type and consistency of use.
• Urinary Symptoms: Dysuria, frequency, urgency.
• Abdominal Pain: Location, severity, and associated symptoms.

Physical Examination:

• General Appearance: Note any signs of distress.
• Abdominal Examination: Palpate for tenderness, especially in the lower quadrants.
• Pelvic Examination (with speculum):
  • Visualization of the cervix for inflammation (cervicitis), discharge, or lesions.
  • Collection of specimens for STI testing (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis).
  • Consider testing for other STIs based on risk factors (e.g., Mycoplasma genitalium, herpes simplex virus).
  • Bimanual examination to assess the uterus and adnexa for tenderness, masses, or enlargement (signs of pelvic inflammatory disease – PID).  
• External Genital Examination: Similar to the 6-year-old, looking for discharge, lesions, or inflammation.  
• Lymph Node Examination: Palpate inguinal lymph nodes.  

Similarities and Differences in Approach

Similarities:

• Detailed History of the Discharge: In both age groups, understanding the characteristics of the discharge is crucial.
• Physical Examination of the External Genitalia: Careful inspection for signs of inflammation, discharge, and lesions is essential.
• Importance of Hygiene: Discussing appropriate hygiene practices is relevant for both age groups.
• Consideration of Trauma or Foreign Body: While more common in young children, trauma should still be considered in adolescents.
• Need for a Respectful and Sensitive Approach: Building trust and ensuring the patient feels comfortable is vital at any age.

Differences:

• Sexual History: This is the most significant difference. It is a primary focus in the 16-year-old and largely absent (except for potential abuse) in the 6-year-old.
• Internal Pelvic Examination: A speculum exam is usually necessary for a sexually active adolescent to visualize the cervix and obtain specimens for STI testing, whereas it is generally avoided in young children unless strongly indicated.  
• Differential Diagnosis: The list of potential causes for yellow vaginal discharge differs dramatically. In the 6-year-old, common causes include non-specific vulvovaginitis, irritants, poor hygiene, pinworms, or less commonly, a foreign body or sexual abuse. In the 16-year-old, STIs become a major consideration, along with bacterial vaginosis and yeast infections.
• Management and Treatment: Treatment in the 6-year-old often focuses on hygiene measures, topical creams if indicated, or removal of a foreign body. In the 16-year-old, treatment depends on the identified pathogen (if any) and may involve antibiotics or antifungals, as well as partner notification and treatment for STIs.
• Counseling and Education: For the 16-year-old, education on safe sex practices, contraception, and STI prevention is essential. For the 6-year-old, education focuses on basic hygiene.
• Legal and Reporting Considerations: Suspected sexual abuse in the 6-year-old necessitates mandatory reporting to child protective services, which is not typically a factor in a 16-year-old’s case.  

In summary, while both cases involve a similar presenting symptom, the approach to history, physical examination, differential diagnosis, and management are significantly different due to the vast difference in age and the potential for sexual activity. My primary concern in the 6-year-old would be to rule out non-sexual causes and consider the possibility of sexual abuse, while in the 16-year-old, STIs would be high on my list of differential diagnoses.