Soru

A 36-year-old woman comes to the clinic for evaluation of severe vulvar itching and vaginal burning that began 5 days ago. Over the past year, she has had four similar episodes. Each prior episode was treated with a single dose of oral fluconazole, which provided only transient partial relief before her symptoms recurred. Her medical history includes type 2 diabetes mellitus. Current medications include metformin and sitagliptin, though she admits to frequently missing doses. Her most recent hemoglobin A1c is 9.4%. Vital signs are temperature 37.0°C (98.6°F), blood pressure 122/78 mmHg, heart rate 78/min, and respiratory rate 14/min. Pelvic examination demonstrates pronounced vulvar erythema and edema with visible excoriations. A moderate amount of thick, white, adherent discharge is present in the vaginal vault. The cervix is visually normal with no bleeding or discharge from the external os, and bimanual examination is unremarkable with no cervical motion tenderness. Vaginal pH is 4.3. Wet mount microscopy with 10% potassium hydroxide preparation reveals numerous small budding yeast cells but is notably negative for pseudohyphae. Which of the following is the most appropriate next step in management for this patient?