Running head: Bacterial Vaginosis SOAP Note 1 Bacterial Vaginosis SOAP Note Student’s name Instructor Course Date Bacterial Vaginosis SOAP Note Date: 2/10/2018 Introduction: KL is a 27-year old female of a Caucasian decent 1. SUBJECTIVE DATA AC: For the last one week, I have been experiencing vaginal discharge that has a foul smell. HPI: Today, the white woman came in our facility with protests of foul smell release from her vagina. This happens each time she engages in sexual relations, and it started about seven days prior. She asserts not to use a condom when engaging in sexual relations. She is explicitly dynamic and has only a solitary accomplice. She says the release is thick and tan. She once in a while has irritation and pain during peeing. She denies stomach pain or vaginal bleeding. Even though it didn't help, she professes to have had an attempt of douching. She rates her side effects at 2/10. PMH: Current medication: Everyday she takes one tab of Tri Sprintec as a method of birth control. Allergies: Not any The client has no acute disease or any major trauma Surgeries/hospitalizations: not any Family History: Her mother is health, though his father has HBP and hyperlipidemia. Paternal grandma has HTN and obese. Her deceased paternal granddad had HTN, while her four year old younger sister is healthy. Social History: the secondary school graduate works at a health recovery center. She lives with her beau however single. She discredits any substance misuse. Has never smoked tobacco ROS: General: Refutes weight change or night sweating, loss of appetite. She denies any chills, fever or fatigue. Cardiovascular: refutes edema, PND, palpitations or chest pain, orthopnea. Skin: refutes any bruising, bleeding, and rashes or delayed healing, lessons changes. Respiratory: refutes haemoptysis, dyspnea, wheezing and cough, TB or pneumonia history. Eyes: Last eye test way March 2017 and she now and then wear contacts. Denies peripheral visual changes, diplopia, ocular pain, trouble focusing, scotoma, obscured vision, or dry eyes. Gastrointestinal: refutes constipation, hepatitis, haemorrhoids, ulcers, disorders, black tarry stools, eating. Gynaecological/Genitourinary: admits to dysuria, occasional urgency Pregnancy history: refutes any history of pregnancy Patient reported menarche at age 13 Vaginal discharge: discharge is thick, tan and has foul odor Menstrual complaints: with last LMP 9 days ago, she denies any menstrual complaint Mammogram: not any Breast Self-Exam: states she conducts breast self-exam every month Last Pap: Says last Pap smear normal in 2016. Musculoskeletal: Denies joint swelling or back pain, stiffness or pain, fracture history, osteoporosis. Ears: Denies hearing loss or ear pain, ringing in ears, discharge. Nose/Mouth/Throat: denies dysphagia or sinus problems, nose bleeds, dental disease, hoarseness, throat pain. 2. OBJECTIVE (O): BP: 122/66 mmHg, Respirations: 19 breaths per min, Pulse: 75 beats per min, Temp: 99.1 F, BMI: 24.4, Height: 5”8”, Weight: 146lbs General Appearance: The woman is very much nourished and healthy appearing and has no acute distress. She is dressed well in clean apparel and is multiple times situated or alert. Skin: it is warm and pink in color, dry, clean, intact. HEENT: Indeed, even dispersion of hair and head has no sores and is normocephalic. Maxillary and facial sinuses have no tenderness — eyes: no scleral infusion or conjunctiva. EOMs are unblemished. Ears: simple to visualize landmarks, Bilateral TMs magnificent dark with positive light reflex, channels patent. Nose: Septal deviation missing. The nasal mucosa is boggy, clogged, and pink. Neck: pharynx has no exudate and is non-erythematous. Oral mucosa is wet and pink. No knobs or thyromegaly, no occipital hubs, cervical lymphadenopathy evident and present. Supple neck with full ROM Cardiovascular: S2, S1 with good mood and rate, no mumbles or rubs, no snaps, no edema. Typical fine refill with 3+ heartbeats all through Respiratory: no back or front wheezes, present lung sounds, unlabored, and standard breaths with symmetric chest walls. A. ASSESSMENT ICD 10 code-N76.1-: Bacterial Vaginosis Differential diagnoses Candidiasis Urinary tract infection B. PLAN (P): There was no further testing. The patient was given Flagyl 500mg PO BID x 7 days as prescription Non-drug medicines - None. Education: The entire course of anti-infection treatment must be done, paying little heed to whether the side effects will fade after certain doses. Douching ought to be dodged as it influences the ordinary vaginal balance. For the most part following a bowel discharge, cleaning ought to be from front to back. CDC (2014) demonstrates this avoids the spreading of microscopic organisms to the vagina from the rectum. Call your doctor if: You ate as yet having side effects of bacterial vaginosis even in the wake of finishing the medication. You have any inquiry. Follow up: to audit vaginal cultures, Pap smear, and pee pregnancy, makes a meeting with the workplace. Patient to be educated regarding any unusual outcome Health: during treatment with nitroimidazoles, stay away from liquor utilization. In the wake of finishing metronidazole, avoid consuming liquor for 24 hours to diminish the odds of a disulfiram-like response (Gideon and Berger, 2019). Continuously utilize your safety belt while driving. The home condition is free and safe from psychological mistreatment and physical dangers. Differential diagnosis rationale Clinical conclusion for candidiasis is made by the presence of vulva redness, swelling, agony and pruritus, and outside dysuria. The real signs are thick curdy vaginal release, abrasions, fissures, and vulvar edema (Gideon and Berger, 2019). An infection or bacterium infecting the kidneys is the reason for Urinary Tract Infection. Both or one of the upper urinary tract is affected, which may comprise of the kidney interstitium, renal pelvis, and ureter. The real side effects are crotch or flank pain, chill, and fever with most frequencies found in youthful grown-ups (CDC. 2014). Nonetheless, more mature adults may have nonspecific side effects, for example, second rate fever and discomfort. References Centers for Disease Control and Prevention (U.S.). (2004). Bacterial vaginosis. Atlanta, Ga: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention. Gideon, I. I., & Berger, S. (2019). Bacterial Vaginosis. Los Angeles: Gideon Informatics, Incorporated.
