SOAP NOTE
Title: L.V Date: 29th August, 2020 Time: 0900 Hrs
Age: 16 years Intercourse: Female
SUBJECTIVE
CC: The affected individual experiences of getting vaginal bleeding and UCG, stomach ache and pelvic ache with some unusual vaginal discharge 2 weeks after having unprotected intercourse.
HPI: The affected individual is G1P0 and is for the time being 4 weeks + 5 days pregnant by the ultimate menstrual interval (LMP) of 15/eight/2020. She had residence being pregnant verify four days up to now. She denies any nausea and is reporting a mild breast tenderness. She has vaginal bleeding and some unusual discharge following the unprotected sexual exercise of two weeks up to now. She experiences of big amount of the yellowish to white vaginal discharge with no odor and she or he is for the time being sporting a pad. The discharge started one to 2 weeks up to now. She on no account expert any ache all through her last sexual exercise. There was no itching nor burning sensation. She denies of any earlier discharge (Elwell et al., 2016).
Medication: She is beneath no drugs at present
PMH: she denies the historic previous of primary illness, accidents, blood transfusion, or hospitalization. She is ready to performing her ADLs effectively.
Allergic reactions: NKDA
Drugs Intolerances: No drugs intolerance
Persistent Sicknesses/Essential traumas: denies any historic previous of energy sickness or primary traumas. She has not been acknowledged with hypertension, diabetes, bronchial bronchial asthma, lung sickness, Tuberculosis, or most cancers.
Hospitalizations/Surgical procedures: denies any historic previous of hospitalization or any surgical course of
Family Historic previous: The mother is a keep and has historic previous of hypertension. Her maternal grandfather is having a historic previous of adult-onset of diabetes mellitus.
Social Historic previous: she resides alongside together with her dad and mother in an area individuals and she or he has no job. She has made an attempt to use for the WIC and the Medicaid benefits last week after finding out about her being pregnant. She is for the time being single with no man to specify as her boyfriend. She denies of any abusive setting (Witkin, Minis, Athanasiou, Leizer , & Linhares , 2017).
ROS
Frequent: she denies fever, no low cost of weight, fatigue, or diminished urge for meals. She experiences of getting widespread weight reduction plan paying homage to fruit and veggies.
Cardiovascular: Denies palpitations or dyspnea on exertion
Pores and pores and skin: No bruises or rashes well-known. No discoloration Respiratory: no shortness of breath, cough, or congestion
Eyes: No use of corrective lenses, no blur, no change throughout the imaginative and prescient
Gastrointestinal: denies nausea, vomiting, and diarrhea.
Ears: No ache of the ear or loss throughout the listening to. Denies of ear discharge
Genitourinary/Gynecological: Denies frequency or urgency in urination or dysuria. There could also be vaginal discharge. No historic previous of pap or mammo
Nostril/Mouth/Throat: Absence of sinus factors, absence of discharges and nostril bleeds, no dental illness, no throatiness, no throat ache, and no dysphagia
Musculoskeletal: stomach ache and pelvic ache
Breast: delicate breast tenderness
Neurological: No seizure, weak spot, blackout out spells, or paralysis.
Heme/Lymph/Endo: the affected individual is HIV detrimental, no bruises, no historic previous of blood transfusion, no night sweats, and chilly or heat intolerance. She denies having swollen glands or enhance in thirst.
Psychiatric: experiences of no earlier illness or despair. She denies of any sleeping
OBJECTIVE
Weight 54 BMI 20.three Temp 97.5 BP 110/70
High 163 cm Pulse 60 Resp 18
Frequent Look: she is alert, cooperating, well-nourished female with no distress, and is unaccompanied to the ability.
Pores and pores and skin: Brown, warmth, clear and intact. No lesions or rashes.
HEENT: Head-normocephalic, atraumatic with no lesions. Even distribution of hair. Eyes: PERRLA and intact EOMs. There’s no conjunctival or scleral injection; Ears-bilateral TMS, patent canals, and the seen landmarks; Nostril-pinkish nasal mucosa, common turbinate and no deviation of the septal; Neck-there is full ROM, supple. Throat-there is pinkish and moist oral mucosa, the pharynx is non-erythematous with no exudate. Tooth is in good restore.
Cardiovascular: there could also be widespread cost and coronary coronary heart rhythm, no gallop or murmur, no tachycardia, pulses are 2+ ×4 ext.
Respiratory: There could also be symmetrical chest wall, widespread and easy respiration, and lungs with clear to bilateral auscultation.
Gastrointestinal: non-palpable liver and spleen, no CVA tenderness, clean and non-tender abdomen, non-palpable fundus, rounded abdomen.
Breast: a mild breast tenderness with no lots or discharge. There’s no dimple, wrinkle, and discoloration of the pores and pores and skin.
Genitourinary: The outside genitalia WNL with no lesions. The speculum examination with out clear, darkish pink, and nulliparous cervix. Heavy deposits of thicker gentle yellowish discharge with no odor. There should not any adnexal lots that is palpable.
Musculoskeletal: Full ROM is seen in the entire 4 extremities as affected individual is able to switch in regards to the examination room.
Neurological: Affected individual A & O × three. The speech is having clear with good tone. She is having erected posture, regular with unchanged gait
Psychiatric: the affected individual is alert and oriented, hold eye contact, responding to the questions in relevant methodology, and clean speech.
Lab Exams
Urine is optimistic for HCG, UA WNL with detrimental glucose, protein, and ketones
There could also be proof of leukocytes beneath moist preparation, absence of trichomonas or clue cells, no hyphae.
Explicit Exams
KOH detrimental beneath whiff verify
Prognosis
Differential Diagnoses
False optimistic being pregnant verify: the optimistic HCG is anticipated for affected individual on the HCG weight reduction plan, molar, or ectopic being pregnant
Ectopic Being pregnant: affected individual denies ache and subsequently, it is rather necessary take into consideration it in differential until there could also be positivity for IUP on sono
Sexually transmitted an an infection i.e. Chlamydia or gonorrhea: that’s doable on account of bigger amount of thicker and yellow discharge. There should not any clue cells, hyphae or the trichomonas seen beneath moist preparation, and the unpredictable utilization of condoms and that’s revealed by the optimistic being pregnant.
Prognosis
Chlamydia: on account of greater amount of discharge and the vaginal bleeding.
Plan/Therapeutics
o Plan:
▪ Full blood rely (CBC) to help within the analysis for anemia; Urine CX on account of prospects of the asymptomatic bacteriuria all through being pregnant; Syphilis, HIV, and the Hepatitis B screening to help within the detection of the STIs that could be a hazard to the fetal effectively being; Gyn Probe for the G/C chlamydia to help within the detection of the sexually transmitted an an infection that will intrude with the well-being of the affected individual; ultra-sound to help within the affirmation of the IUP and the EDD; Rubella and the VZC titer to forestall the publicity of the fetus to the possibility of the detrimental titer of the mother; and the blood kind and the rhesus elements to help in determine the doable Rh incompatibility in case the mother is Rh-.
▪ Drugs: Azithromycin 19 PO ×1; ceftriaxone 250 mg IM ×1, and the retest on the next go to.
▪ Coaching: The affected individual is educated to avoid sexual train until seven days; affected individual is recommended to make a reputation or return to the ability in case the indicators fail to reduce; affected individual taught to avoid douches or totally different vaginal irritants; affected individual advised to plan for the prenatal care by visiting. The affected individual is recommended to call the provider when she experiences the indicators related to the bleeding, fever, contractions, important or abrupt swell, and ROM. Affected individual is recommended to have a nutritious eating regimen i.e. enhance throughout the fruit and veggies along with lean protein. The affected individual is recommended to not take clean or unpasteurized cheeses.
▪ Non-medication cures: The affected individual can take garlic as a result of it has antibacterial and the anti-inflammatory outcomes. It moreover has the antifungal properties that battle the enlargement of yeast which makes it helpful in the middle of the antibiotic remedy for chlamydia (Wilson, 2019).
Assessment of affected individual encounter: The affected individual is alert and well-oriented, nevertheless she has a precedence about her vaginal bleeding and totally different indicators that is supplied throughout the facility. She simply is not successfully educated about her scenario, subsequently, requires every medical and education consideration throughout the administration of her scenario.
References
Elwell, C., Mirrashidi, Okay., & Engel, J. (2016). Chlamydia cell biology and pathogenesis. Nature Opinions Microbiology, 14(6), 385-400.
Wilson, R. D. (2019, March 26). Why Home Therapies for Chlamydia Are a Harmful Idea. healthline: https://www.healthline.com/effectively being/sexually-transmitted-diseases/home-remedies-for-chlamydia
Witkin, S., Minis, E., Athanasiou, A., Leizer , J., & Linhares , I. M. (2017). Chlamydia trachomatis: the persistent pathogen. Medical and Vaccine Immunology, 24(10).
