Gynecologic Health
Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note 1 OR 2 PAGES :
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?
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 for this patient , as well as a rationale for this treatment and management plan.
Very Important: Reflection notes: What would you do differently in a similar patient evaluation?
Reference
Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.
Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.
Chapter 6, “Care of the Well Woman Across the Life Span” ,“Care of the Woman Interested in Barrier Methods of Birth Control” (pp. 275–278)
Chapter 7, “Care of the Woman with Reproductive Health Problems”
“Care of the Woman with Dysmenorrhea” (pp. 366–368)
“Care of the Woman with Premenstrual Symptoms, Syndrome (PMS), or Dysphoric Disorder (PMDD)” (pp. 414–418) 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. He 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
SOAP Note – Bacterial Vaginosis Case Study
Introduction
This SOAP (Subjective, Objective, Assessment, and Plan) note presents a case study of a patient with bacterial vaginosis (BV), a common gynecologic health issue. The patient’s personal and medical history, physical assessment, differential diagnoses, primary diagnosis, and the treatment plan will be discussed in detail.
Subjective:
The patient, a 26-year-old Hispanic American female, presented with a chief complaint of vaginal itching, thin gray vaginal discharge, and a strong foul fishy odor, especially after sexual intercourse. She reported that these symptoms had been ongoing for the past week. The patient also mentioned a burning sensation during urination but denied other systemic symptoms such as fever, chills, nausea, or vomiting. Her menstrual history indicated that her last menstrual period was on 06/09/2016, with a normal Pap smear result in May 2016. She reported a single sexual partner and no contraceptive use.
Objective:
The physical examination revealed a well-nourished and non-distressed patient with vital signs within normal limits. A head-to-toe examination, including the head, eyes, ears, nose, throat, neck, chest, lungs, heart, abdomen, genital, musculoskeletal, neurological, and skin, was performed. Notable findings included thin gray watery vaginal discharge with a foul fishy odor.
Assessment:
The patient underwent urine dipstick testing, which yielded negative results. A pelvic/vaginal examination showed positive results for wet mount, whiff test, and vaginal pH, confirming BV. Based on this, the primary diagnosis is bacterial vaginosis. Differential diagnoses of vaginal candidiasis and trichomoniasis were ruled out due to differences in vaginal discharge characteristics.
Plan:
For diagnostic confirmation, an oligonucleotide probes test will be ordered and sent to an external diagnostic lab. The patient will receive antibiotic therapy with Metronidazole (Flagyl), 500 mg orally twice daily for seven days. Alternative therapies, including probiotics, apple cider vinegar, and hydrogen peroxide, will be recommended. Nonpharmacological treatments such as yogurt, tea tree oil, and garlic consumption will be advised to help restore vaginal pH balance and eliminate bad bacteria. Health promotion measures will include hygiene practices and lifestyle changes to prevent recurrence. A follow-up appointment in 14 days for re-evaluation and possible re-treatment will be scheduled.
Reflection Notes:
In a similar patient evaluation, it would be beneficial to consider a hemoglobin A1C test to rule out diabetes as a contributing factor. Additionally, allowing the patient to try home remedies before starting antibiotic therapy might be considered to prevent antibiotic resistance. The patient’s response to treatment and the potential need for re-treatment should also be closely monitored.
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 solutions. 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). Bacterial vaginosis. Retrieved from http://womenshealth.gov/publications/our-publications/fact-sheet/bacterial-vaginosis.html
Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.
Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.
• 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.
