Soap Note 1 - Soap PDF

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SOAP NOTE

.CC: Patient presents to the office complaining of vaginal discharge and foul odor

HPI: Patient is a 34-years-old hispanic female who presents to the office complaining of vaginal itching with vaginal discharge. Patient reports that the vaginal discharge has a strong fishy odor which she noticed that was stronger after having sex. She states that she first had the symptoms a week ago. She reports that have a new sexual partner and her relationship started 3 months ago. Patient admits that she has not seen any doctor for this condition and this if the first time she seek medical attention. Reports that she is not taking any medication to alleviate the symptoms. However, she reports the use of Monistat ovule one-time dose when she first noticed her symptoms but believes it is not working. She denies use of douches or any lotions. Reports that .her last menstrual period was on 12/20/2021 :Current Medications Monistat ovule over the counter for vaginal itchy.

PMH Past Medical History: None Past Surgical History: None Hospitalizations: None

:Family History Mother is 58-years old, alive: Healthy Father is 62-years old, alive: HTN, DM, Hyperlipidemia. Siblings: Brother: 28-years-old: Obesity Sister: 31-years-old: Healthy

:Social History YM works as a secretary at a Lawyers office and reports that she has a moderate level of stress at her work. She identifies herself as heterosexual and reports a new sexual partner 3months ago. She denies history of tobacco use, illicit drugs, and drinks socially. She reports no recent travel

SOAP NOTE Cardiovascular: Denies chest pain, palpitations, General : General: Denies changes in weight . dyspnea on exertion, orthopnea, or edema or fatigue. She denies fever, chills, or night sweats Respiratory: She denies shortness of breath, Skin: Denies presences of rash, or itching. Not wheezing, cough, hemoptysis, bronchitis, .change in nails/hair, no cyanosis emphysema or tuberculosis Gastrointestinal Denies nausea, vomiting, diarrhea, or constipation. Bowel movements . are daily with normal color and consistency

Eyes: Denies problems or changes in his vision; denies double or blurred vision. Last :eye exam

Genitourinary: Denies burning urination or blood Ears: Denies difficulty or changes in his in urine. Reports vaginal itching with thin, gray hearing. Denies tinnitus, discharge, or vaginal discharge. Reports vaginal discharge with .discharges foul, fishy odor; reports vaginal odor particularly strong with a fishy smell after sex, denies STDs. .Last Pap smear last year with normal findings

Nose/Mouth/Throat Denies itching. No sinus pain. No Bleeding gums no lesion in mouth or tongue. Denies sore throat or sinus pain.

Musculoskeletal Denies cramps, joint stiffness. Denies musculoskeletal injuries, fractures of changes in range of motion. Denies muscles or joint pain.

Breast Denies pain, rash, tenderness, or swelling. Denies breast lumps, no nodules, no nipple drainage, no nipple retraction

Neurological Denies history of seizures, stroke, memory loss. No weakness, paralysis, numbness/tingling, or coordination problems.

Heme/Lymph/Endo Denies pain, tenderness.

Psychiatric Denies depression, mood changes, or suicidal ideations. Denies history of mental illness

General Appearance Patient is a 34-years-old hispanic female in no acute distress. Well nourished and maintains eye contact throughout interview and examination.

Skin Warm and dry to touch. Normal temperature, No rashes, no lesions. HEENT Head: Normocephalic, atraumatic. Scalp with no masses, normal hair distribution. Eyes: Equal hair distribution to bilateral eye, no lesions, no ptosis, no lesions. PERRLA bilateral. Ears: External ear canal without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Nose: Septum is midline, nasal mucosa is boggy, and pale bilaterally. Mouth/throat: Moist buccal mucosa. Adequate dental hygiene. Uvula midline. Neck and Regional Lymph Nodes: Symmetric and supple. Non-tender without cervical lymphadenopathy, masses, or thyromegaly. No carotid bruits, or jugular vein distention. Cardiovascular S1, S2 noted with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs noted. Capillary refill normal at 2 seconds. No edema noted.

Respiratory: Respirations even and unlabored. Chest Symmetrical anterior and posteriorly bilaterally. Lungs clear to auscultation bilaterally Gastrointestinal: Abdomen is soft, non-tender and non-distended. Bowels sounds are present in all 4 quadrants. No abnormal aortic pulsations. No ascites.

Breast No reported any change. There is no axillary adenopathy or tenderness. Breasts appear to be symmetric. There was no nipple discharge or retraction. Upon palpation, there were no palpable lumps or bumps.

Genitourinary No tenderness noted to the suprapubic area. Urine clear and straw color. Genitalia/Reproductive: Pelvic exam reveals a large amount of Gray, thin, watering vaginal discharge with foul fishy odor noted. No lesions or abnormalities were noted to the cervix. The uterus is normal size.

Musculoskeletal: Full range of motion present in all extremities. No varicose vein, clubbing, cyanosis, or edema present. Palpable peripheral pulses present. No joints and muscle tenderness Normal muscular development Normal gait Neurological: AAOx3.Level of consciousness is normal, Speech Normal, no neurological focalizations, no sensory-perceptions disorders. Cranial Nerves: I-XII grossly intact. No altered t l t t Psychiatric: Normal, no signs or symptoms of depression, no anxiety, no suicidal ideas. Appropriate thought process

Special Tests Primary Diagnosis- (ICD 10:N77.1 ) Bacterial Vaginosis: (BV) is an infection of the vagina. It results from a change in the normal balance of vaginal bacteria. BV usually doesn't cause any other health .problems. But it can lead to issues, especially when you're pregnant or trying to get pregnant Differential Diagnoses

1. Vaginal Candidiasis: (ICD10: B37.3) 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). 2. Trichomoniasis: (ICD10: A59.9)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. Trichomoniasis is ruled out as the possible differential diagnosis because the patient discharge is not frosty, yellow-green. PLAN/INTERVENTIONS: Medications: Flagyl 500mg PO BID x 7 days. Diagnostic tests: None Education: Education: Take your medication as directed. Do not stop taking them just because you feel better. You need to take the full course of treatment. Do not eat or drink anything that contains alcohol if you are taking metronidazole or tinidazole. Wear loose cotton clothing. Do not wear nylon and other materials that hold body heat and moisture close to the skin. Do not wash your vaginal area more than once a day. Use plain water or a mild, unscented soap. Do not douche.

RTC: Follow up in one week or return to the clinic if symptoms do not improve.

References Sobel, J., & Mitchell, C. (2020, March 24). Candida vulvovaginitis: Clinical manifestations and diagnosis. Retrieved January 16, 2021, from https://www.uptodate.com/contents/candidavulvovaginitis-clinical-manifestations-and-diagnosis#H86369992 Vulvovaginal Candidiasis - 2015 STD Treatment Guidelines. (2015, June 04). Retrieved January 16, 2021, from https://www.cdc.gov/std/tg2015/candidiasis.htm Willems, H., Ahmed, S. S., Liu, J., Xu, Z., & Peters, B. M. (2020). Vulvovaginal Candidiasis: A Current Understanding and Burning Questions. Journal of fungi (Basel, Switzerland), 6(1), 27. https://doi.org/10.3390/jof6010027...