SOAP note week 3 women’s Health – 26-year-old Hispanic female, with vaginal discharge
SOAP note on WOmens Health 26 Hispanic yr female, with a complaint of increased vaginal discharge that is white, odorous for 5 days. I will send you the template in the files, you can make up the rest of the information. Differential diagnosis should be 1(primary)- Bacterial vaginosis, 2-trichomonas 3-chlamidia 4- Gonarrhea
Select a patient that you examined during the last three weeks. With this patient in mind, address the following in a SOAP Note:
Subjective: What details did the patient provide regarding her personal and medical history?
Objective: What observations did you make during the physical assessment?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why? SOAP note week 3 womens Health – 26 year old Hispanic female, with vaginal discharge
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation?
Week 3 Soap Note: Bacterial Vaginosis
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
BUY A PLAGIARISM-FREE PAPER HERE
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 the patient advised to eat two cups of plain yogurt daily. The rationale is to restore the 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, the patient will instructed to eat raw or cooked garlic daily because the garlic natural antibiotic properties. The rationale is to keep 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). SOAP note week 3 womens Health – 26 year old Hispanic female, with vaginal discharge.
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 SOAP note week 3 womens Health – 26 year old Hispanic female, with vaginal discharge
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 SOAP note week 3 womens Health – 26 year old Hispanic female, with vaginal discharge
�Unnecessary
�Unnecessary in this case
�Unnecessary in this case
BUY A PLAGIARISM-FREE PAPER HERE
�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. SOAP note week 3 womens Health – 26 year old Hispanic female, with vaginal discharge
NURS 6551 Week 3 Discussion post
Scenario One
A 23-year-old Caucasian female present with concerns about mood swings around the time of her menses. She believes she has PMS and wants to know if there is a medication to control it.
I think this scenario is a great and most likely a common situation that we will all encounter in practice in any field such as Women’s health or primary care. The three phase menstrual cycle is a physiologic change that occurs in a pattern consistency and is hormone driven resulting in many women experiencing functional cyclic pain and related symptoms (Schuiling & Likis, 2017). Scientific evidence has shown that hormones, such as estrogen, play a pivotal role in reproductive, cardiovascular, skeletal, and central nervous systems focusing on the control of energy expenditure, food intake, white adipose distribution as well as insulin sensitivity, inflammation, and lipid accumulation (Mauvais- Jarvis, Clegg, & Hevener, 2013 With that being said, it is evident that a fluctuation in hormonal changes can have physiological and behavioral impacts. Unfortunately, there is a stigma for females regarding the seriousness of physiologic changes that occur in regards to menstruation for which many studies have been conducted. SOAP note week 3 womens Health – 26 year old Hispanic female, with vaginal discharge.
As a provider in this scenario, I feel the most important next step in managing her care is to recognize that what she is experiencing are indeed real symptoms for a real condition for women. This establishes trust and rapport with patients and validates their feelings. The last thing a provider should do is dismiss the feelings and concerns of a patient. The provider should inquire about the specific symptoms the patient is experiencing and the frequency of occurrence to accurately diagnose. The patient should be encouraged to keep a journal of her symptoms and dates to help establish a timeline to aide in diagnosis. The Daily Record of Severity Problems (DRSP) is an assessment tool used to document the frequency and intensity of emotional and physical symptoms associated with the menstruation cycle (Ryu & Kim, 2015). Also, a thorough past medical history is indicated as Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) can mimic or exacerbate other disorders such as anxiety, depression, chronic fatigue syndrome, or thyroid disease (Schuiling & Likis, 2017).
Premenstrual Syndrome & Premenstrual Dysphoric Disorder
Premenstrual disorders consist of psychiatric or somatic symptoms that develop within the luteal phase of the menstrual cycle and can affect the patient’s normal daily functioning and resolve shortly after menstruation (Hofmeister & Bodden, 2016). Differentiating between PMS and PMDD can pose challenges as both disorders may have the same clinical manifestations. It is the severity of the symptoms that differentiate the two disorders. PMS is defined as a cluster of mild to moderate physical and psychological symptoms and PMDD encompass cognitive, behavioral, emotional, and negative symptomatic changes that severely impair daily functioning (Schuiling 7 likis, 2017). According to Schuiling & Likis (2017) approximately 80% of all women report one or more physical, psychological, or behavioral symptom during the luteal phase of their cycles, although not all of these women report disruption in their normal lives (p.557, para 5). The most commonly reported symptoms of PMS include abdominal pain, bloating, and cramping, water retention and weight gain, constipation, diarrhea, headache, fatigue, nausea, food cravings, depression, anxiety, anger, irritability, insomnia, changes in libido, feelings of low self-esteem, and even social withdrawal (Schuiling & Likis, 2017). The common clinical manifestations of PMDD are similar to PMS except they are intensified and can include marked irritability and increased interpersonal conflicts, markedly depressed mood and feelings of hopelessness and self-deprecating thoughts, difficulty concentrating, lethargy, and a general sense of being overwhelmed and our of control (Schuiling & Likis, 2017). The American College of Obstetricians and Gynecologist (ACOG) (2015) state that in order to diagnose PMS or PMDD a patient must accurately report and record their symptoms (previously mentioned) for at least two to three months and the symptoms must be present in the 5 days before her period for at least three menstrual cycles in a row, end within 4 days after her period starts, and interfere with some of her normal activities. SOAP note week 3 womens Health – 26 year old Hispanic female, with vaginal discharge.
Contraception as Treatment
Once an official diagnosis of either PMS or PMDD is made, the provider and patient should communicate common goals and discuss a collaborative approach for management. The first focus should be on modifiable factors contributing to symptoms of PMS/PMDD and can include a balanced diet and hydration, regular exercise, adequate sleep, smoking cessation, and stress reduction (Schuiling & Likis, 2017). In terms of choosing the correct pharmacological intervention, the provider needs to determine if the patient is experiencing more physical disturbances of psychological issues. Medications can be used to address the body’s hormonal activity through suppression of ovulation, or they can be used to affect the concentration of neurotransmitters such as serotonin, norepinephrine, or dopamine (Hofmeister & Bodden, 2016). Schuiling & Likis (2017) state that selective serotonin reuptake inhibitors (SSRI) medications are highly effective in the treatment of the symptoms of PMS/PMDD. Combined oral contraceptives (COC) are the contraceptive method of choice for PMS/PMDD symptoms due to the regulation of menses, symptom suppression, and contraception. The COC containing drospirenone 3mg plus ethinyloestradiol 20mcg (Yaz) may be the most effective in treating severe premenstrual symptoms (Stewart & Black, 2015). COC containing drosoirenone/ethinylestradiol are beneficial in PMS/PMDD due to their antimineralcorticoid activity (diuretic like) resulting in less fluid retention and clinical effects on clearing the skin (Machado, Pompei, Giribela, & Giribela, 2011). If a patient is experiencing severe PMDD then combination therapy of SSRI and contraceptives may be warranted.
Managing Differing Opinions in the Plan of Care
It is essential as a provider to recognize the differences that will occur between scientific evidence for disease treatment and a patient’s beliefs and requests. It is vital that providers discuss the background of a situation and develop a common goal for management before determining the best treatment. There are many people that are opposed to taking daily medications and prefer lifestyle modifications and holistic approach and if that is not something you are able to accommodate as a provider, than a referral should be made. Providers should always listen and respect the wishes of patients and involve them in their own treatment plans and providing appropriate education is key. Tharpe, Farley, and Jordan (2017) state that treatment should be aimed at finding relief measures that are acceptable for the individual and must support the patient in the context of their life. SOAP note week 3 womens Health – 26 year old Hispanic female, with vaginal discharge.
References
American College of Obstetricians and Gynecologist. (2015). Premenstrual syndrome:
FAQ. Retrieved from https://www.acog.org/-/media/For-Patients/faq057.pdf
Hofmeister, S. & Bodden, S. (2016). Premenstrual syndrome and premenstrual dysphoric
disorder.
American Family Physician, 1;94
(3), 236-240. Retrieved from http://www.aafp.org/afp/2016/0801/p236.html
Machado, R. B>, Pompeo, L. M., Giribela, A. G., & giribela C. G. (2011).
Drospirenone/ethinylestradiol: A review on efficacy and noncontraceptive benefits.
Women’s Health (London), 7
(1), 19-30. doi:10.2217/whe.10.84
Mauvais-Jarvis, F., clegg, D. J., & Hevener, A. L. (2013). The role of estrogens in control
of energy balance and glucose homeostasis.
Endocrine Soceity 34
(3), 309-338. doi:10.1210/er.2012-1055
Ryu, A., & Kim, T. (2015). Premenstrual syndrome: A mini review.
Maturitas, 82
(4),
436-440. doi:10.1016/j.maturitas.2015.08.010
Schuiling, K. D., & Likis, F. E. (2017).
Women’s gynecologic health
(3
rd
ed.). Burlington,
MA: Jones and Bartlett Publishers
Stewart, M., & Black, K. (2015). Choosing a combined oral contraceptive pill.
Australian
Prescriber, 38
(1), 6-11. doi:10.18773/austprescr.2015.002
Tharpe, N. L., Farley, C., & Jordan, R. G. (2017).
Clinical practice guidelines for midwifery & women’s health
5
th
ed.). Burlington, MA: Jones & Bartlett Publishers. SOAP note week 3 womens Health – 26 year old Hispanic female, with vaginal discharge