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Week 3 Soap Note: Bacterial Vaginosis

Bethel U. Godwins

Walden University

NURS 6551, Section 8, Primary Care of Women

June 17, 2016

Week 3 Soap Note: Bacterial Vaginosis

Patient Initials: WJ Age: 22 Gender: Female

SUBJECTIVE DATA:

Chief Complaint: “I have vaginal itching with discharge and foul odor for the past one week ”

History of Present Illness: WJ is a 26-year-old Hispanic American female who presented to the clinic with complaint of vaginal itching with thin, gray vaginal discharge. Patient reported that the vaginal discharge has a strong foul, fishy odor, and the vaginal odor was particularly strong with a fishy smell after sex for the past one week. Patient stated that she has burning on urination, but denied fever, chills, nausea or vomiting. She reported that she decided to see a health care provider because she could not tolerate the odor, burning and discharge anymore.

Location: Vaginal

Duration: One week.

Quality: Itching, gray vaginal discharge; strong foul odor with fishy smell

Radiation: None

Severity: 8/10 on a scale of 1 to 10.

Timing/Onset: One week ago, but worse in the past 2 days.

Alleviating Factors: None

Aggravating Factors: sexual intercourse

Relieving Factors: Sitz bath

Treatments/Therapies: None except warm sitz bath

Medications: None

Allergy: No known drug or food allergy.

Past Medical History: None

Past Surgical History: None

GYN History: LMP 06/09/2016; last Pap smear 05/2016; result: WNL; menarche 12; cycle 5 days; age of first intercourse 18 year; number of partners one; no contraceptive, heterosexual.

OB History: Gravida: 0 Para: 0

Personal/Social History: Single; denied recreational drug/alcohol use. Lives alone. Sexually active.

Immunizations: up to date with vaccination; positive influenza vaccine in November 2015. Negative Pneumococcal vaccine.

Family History: Diabetes: father; hypertension: Mother; both parents still living .

Review of Systems:

General: Patient appeared well nourished; active, denied change in weight .

HEENT: Patient denies headache or head injury, wears contact lenses, denies nasal/sinus congestion or drainage. Denies hearing problem, tinnitus or vertigo. H e reports that he had his dental exam within the last 6 months, and denies any bleeding gums, gingivitis or ulceration lesions; denies chewing or swallowing problem.

Neck: Denies neck pain, tenderness, swelling, or neck injury.

Respiration: Denies difficulty breathing, cough or coughing up blood, or dyspnea at rest .

Cardiovascular: Denies chest pain, SOB, palpitations, edema, arrhythmias, and heart murmur. Gastrointestinal: Denies abdominal pain, nausea, vomiting, or changes in bowel/bladder regularities. Admits good appetite.

Peripheral Vascular: denies any peripheral vascular problem .

Urinary: Reports burning on urination, denies back pain, frequency, blood in the urine.

GYN: Reports vaginal itching with thin, gray vaginal discharge. Reports vaginal discharge with strong foul, fishy odor; reports vaginal odor particularly strong with a fishy smell after sex, denies STDs.

Musculoskeletal: Denies joint pains, joint stiffness, or problem with joints range of motion.

Psychiatry: Denies anxiety, depression, mood changes, and mental health. Denies any suicidal ideation or attempt.

Neurological: Denies memory loss, dizziness, tingling/numbness, falls, and seizures.

Integument/Hematology/Lymph: Denies bruising easily, skin rashes, dryness, itching, skin lesions and cancer. Denies any clotting or bleeding disorders. Denies transfusion reaction.

Endocrine: Denies diabetes, thyroid problem, heat or cold intolerance.

Allergic/Immunologic: Denies allergic rhinitis, denies immune deficiencies.

OBJECTIVE DATA

Physical Exam:

General: Alert and oriented. Appeared well-groomed. Patient does not appeared to be in any acute distress. Vital signs: B/P 116/74, left arm, sitting; P 76; RR 18; SPO2 100% RA. Weight 132 pounds, BMI 20.53, Height 65 inches.

HEAD: Head round and symmetry, no lesions, bumps, nodules, or injury noted.

EENT: PERRLA, clear conjunctiva and sclera; hearing intact bilateral; TMs visualized, pearly grey; clear nasal passage, normal turbinates, septal deviation absent. Oral mucosa pink and moist .

Neck: thyroid supple, midline trachea, no thyromegaly or lymphadenopathy

Chest/Lungs: Chest wall symmetrical, no use of accessory muscles note, breath sound are clear to auscultation, no wheezing, rhonchi, or prolonged expiration noted in the upper/lower lung fields. No nipple discharges or abnormal lump noted.

Heart: S1, S2 noted with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs noted. Capillary refill normal at 2 seconds. Pulses palpable/normal at 2+. No edema noted.

Abdomen: Abdomen is soft, non-tender and non-distended. Bowels sounds are present in all 4 quadrants. No hepatosplenomegaly.

Genital: Gray, thin, watering vaginal discharge with foul fishy odor noted.

Musculoskeletal: Full range of motion present in all extremities. No varicose vein, clubbing, cyanosis, or edema present. Palpable peripheral pulses present .

Neurologic: Alert and oriented; ambulatory with steady gait. Speech clear/audible. All extremities movable. Touch sensation and two- point discrimination present and intact .

Skin: No rashes, nodes, lumps, ulcers noted. Skin moisture good and turgor is intact.

ASSESSMENT:

Lab Test and Results:

Urine dipstick: Negative

Pelvic/Vaginal examination: showed gray thin watering discharge with foul, fish odor, vaginal swab obtained for microscopic examination, such as

wet mount test; whiff test; vaginal pH test, and oligonucleotide probes test (send out test).

Swap applied to wet mount for whiff amine test, clue cells test, and applied to litmus paper to check for pH. Results: KOH positive for fishy odor; pH 5.2; wet mount: clue cells present

Differential Diagnosis :

1. Bacterial Vaginosis

2. Vaginal Candidiasis

3. Trichomoniasis

Primary Diagnosis:

Bacterial vaginosis (BV): is the primary diagnosis. Women’s Health (WH, 2015) describe bacterial vaginosis as the vaginal infection that results from overgrowth of bacterial usually found in the vagina which disrupt the natural balance. Bacterial vaginosis can affect women of any age, but usually affect women in their reproductive years. According to WH (2015) signs and symptoms include vaginal discharge that is white or milky or gray in color. Also, the discharge can be watery or foamy with strong fishy odor usually after sex; itchy, irritating vagina, and burning on urination. Moreover, WH (2015) explained that diagnosis are made based on vaginal exam, results of swap vagina fluid obtained during physical examination, such as wet mount test; whiff test; vaginal pH test, and oligonucleotide probes test results. Diagnosis can be made based on the result of three out of the four tests according to WH (2015). The rationales for identifying bacterial vaginosis as the primary diagnosis are that patient’s pelvic/vaginal examination revealed thin, watery, grey discharge. Also, laboratory test for wet mount test; whiff test; vaginal pH test are all positive, and when these tests are positive with the vaginal discharge that is synonymous with bacterial vaginosis, the diagnosis of bacterial vaginosis is established.

Vaginal Candidiasis: Commonly known as yeast infection. The infection is caused by fungus candida, which causes extreme itching, swelling, and irritation. Symptoms include rash, vaginal discharge that is usually thick, white, and odorless; itching, burning, pain during sex, soreness, and burning. Vaginal candidiasis is ruled out as the primary diagnosis because of the difference in the vaginal discharge, which is odorless, thick, and white like cottage cheese unlike bacterial vaginosis (Center for Disease Control and Prevention [CDC], 2016).

Trichomoniasis: The CDC (2016) explained that trichomoniasis is a sexual transmitted disease. the infection is caused by protozoan parasite known as trichomonas vaginalis. The infection is transmitted from an infected person to an uninfected person during sex. In addition, CDC (2016) explained that the signs and symptoms trichomoniasis to include mild irritation to severe inflammation, burning, itching, redness or soreness genitals; discharge can be thin, frosty, greenish, yellowish, clear or white with unusual smell. The CDC (2016) stipulated that trichomoniasis cannot be diagnosed based on symptoms alone. Laboratory test or check is needed to diagnose the infection. Trichomoniasis is ruled out as the possible differential diagnosis because the patient discharge is not frosty, yellow-green.