Pelvic exam soap note example

Running head: Week 3 soap note 1

Week 3 soap note 2

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.

PLAN:

Diagnostic plan: Oligonucleotide probes test will be ordered and send out to outside diagnostic lab company. Wet mount test, KOH/whiff test, and litmus test for pH were all ordered and tested. Results: positive.

Treatment and Management:

Bacterial vaginosis resolved spontaneously for most women, but the patient has been having the symptoms for one week. I will use an antibiotic therapy.

Antibiotics Therapy:

Metronidazole (Flagyl), 500 mg orally twice daily for seven days .

Alternative Therapy

I will recommend probiotics, such as Lactobacillus acidophilus, which will help eliminate high levels of bad bacteria and replace them with good bacteria. The rationale is that acidophilus is a known good bacteria. Also, I will recommend apple cider vinegar; the rationale is that bacterial vaginosis is caused be change in vaginal pH. The apple cider vinegar is natural acidic compound and will help regulate the patient body pH and naturally restore pH balance (Machado, Castro, Palmeira-de-Oliveira, Martinez-de-Oliveira, & Cerca, 2015). In addition, I will recommend hydrogen peroxide because hydrogen peroxide is natural disinfecting agent, and patient will be directed to insert tampon soaked with 3% hydrogen peroxide purchased at drugstore, the goal is to eliminate bad bacteria in the patient body (Machado et al., 2015).

Nonpharmacological Treatment:

Yogurt will be recommended to the patient, and patient advised to eat two cups of plain yogurt daily. Rationale is to restore normal pH balance in the vagina inhibiting the growth of bad bacteria. Moreover, tea tree oil will be recommended to the patient, and patient will be instructed to add few drops of tea tree oil in warm water, stir the water and use the water to rinse vaginal daily for three to 4 weeks (Machado et al., 2015). The rationale is to kill the bacteria that cause bacterial vaginosis as well as eliminate the foul fishy odor associated with bacterial vaginosis because tea tree oil has both natural antibacterial and antifungal compounds. Furthermore, patient will instructed to eat raw or cooked garlic daily because the garlic natural antibiotic properties. The rationale is to keep the eliminate bad bacterial (Machado et al., 2015).

Health Promotion:

Patient will be educated to wipe from front to back instead of back to front to void contaminating the vagina with bacterial from the rectum. Also, patient will be educated to keep her vulva clean and dry. In addition, patient will be educated to refrain from using agents that are irritating in her vagina, such as strong soaps, feminine hygiene sprays, or douching. Furthermore, patient will be educated to abstain from tight jeans, panty hose with no cotton crotch, or clothing that trap moisture. Have only single sex partner and use condom (Public Health, 2015).

Reflection Note and Follow-Up

What I will do differently on a similar patient evaluation is that I will check the patient hemoglobin A1C to rule out diabetic origin of the condition . I would send the patient home to try the recommended home remedies for few days and come back for antibiotic treatment since bacterial vaginosis can be resolved without treatment to prevent antibiotic resistance. Patient will be schedule to follow-up in 14 days to repeat the diagnostic test to make sure that the infection is cleared, and if the infection is not cleared, I will repeat antibiotic treatment. I agree with my preceptor diagnosis based on the available positive test results and clinical guidelines .

References

Centers for Disease Control and Prevention. (2016). Genital/vulvovaginal candidiasis.

Retrieved from http://www.cdc.gov/fungal/diseases/candidiasis/genital/index.html

Centers for Disease Control and Prevention. (2016). Trichomoniasis. Retrieved from

http://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm

Machado, M., Castro, J., Palmeira-de-Oliveira, A., Martinez-de-Oliveira, J., & Cerca, N.

(2015). Bacterial vaginosis biofilms: Challenges to current therapies and emerging solution. Front Microbiol, 6, 1528-1542. doi: 10.3389/fmicb.2015.01528

Public Health. Bacterial vaginosis: Women’s health guide. Retrieved from

http://www.publichealth.va.gov/infectiondontpassiton/womens-health-

guide/bacterial-vaginosis.asp

Women’s Health. (2015). Bacteria vaginosis. Retrieved from

http://womenshealth.gov/publications/our-publications/fact-sheet/bacterial-

vaginosis.html

SOAP note rubric

Subjective (15 points)

Points Possible

Points Earned

· CC

1

1

· Pertinent positives (OLDCARTS)

5

5

· Pertinent negatives & positives (from ROS)

5

4

· Pertinent PMH, SH, and FH

3

3

· Medications and drug/food allergies are included

1

1

Objective (15 points)

· VS including FHT if indicated

3

3

· Thyroid, Heart, and Lungs

1

1

· Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included.

-5

1

· Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted.

-5

5

· Diagnostic test results (ex; BHCG, CBC, Rubella, RPR, pap, GC, CT, 1 HR GTT, GC/CT, urine dip, wet prep, Blood group & RH Status)

2

2

Assessment (10 points for each priority diagnosis to equal 30)

30

30

Plan (15 points)

· Medications discontinued ("d/c lisinopril 10 mg daily”)

1

NA/1

· Medications started (“start Ferrous Sulfate 325 mg daily”)

2

2

· Alternative therapies if appropriate (1 point)

1

NA/1

· Diagnostic tests ordered with timeframe

6

6

· Referrals or consultations if appropriate

2

2

· Follow-up interval

3

3

Reflection notes (25 points)

· What did you learn from this experience? Any ah-ha’s? (5 points)

5

0

· What would you do differently?

5

5

· What additional data would you have gathered?

5

5

· What additional elements of the exam would you have done?

5

0

· Do you agree with your preceptor based on the evidence?

5

5

Total points

100

85

Overall great work on your first SOAP note, please see comments.

�Great CC, clear concise in patient’s own words.

�Great use of OLDCARTS

�Great history

�Any fever, chills, fatigue?

�She

�Unnecessary

�Unnecessary

�Unnecessary in this case

�Unnecessary in this case

�Unnecessary in this case

�Unnecessary in this case

�Great

�Great choice, first line treatment for BV

�This may be beneficial in recurrent cases however besides fam hx, patient does not have any other risk factors, young, normal BMI.

�In The reflections you are to list What did you learn from this experience? Not addressed.

What would you do differently? You addressed this.

What additional data would you have gathered? You addressed this.

What additional elements of the exam would you have done? Not addressed

Do you agree with your preceptor? You addressed this.

See SOAP note template, even if you don’t have anything to add, just state that with the question.