Running head: Week 3 soap note 1
Week 3 soap note 2
Bethel U. Godwins
NURS 6551, Section 8, Primary Care of Women
June 17, 2016
Week 3 Soap Note: Bacterial Vaginosis
Patient Initials: WJ Age: 22 Gender: Female
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 a 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 week. The patient stated that she has burned 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.
Duration: One week.
Quality: Itching, gray vaginal discharge; strong foul odor with a fishy smell
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
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; the age of first intercourse 18 years; the 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: The patient appeared well-nourished; active, denied a 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 a 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.
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.
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
Bacterial vaginosis (BV): is the primary diagnosis. Women’s Health (WH, 2015) describe bacterial vaginosis as the vaginal infection that results from an overgrowth of bacterial usually found in the vagina which disrupts 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 a strong fishy odor usually after sex; itchy, irritating vagina, and burning on urination. Moreover, WH (2015) explained that diagnoses are made based on the vaginal exam, results of swap vagina fluid obtained during a 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 tests 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 a 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 sexually transmitted disease. the infection is caused by a 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 of trichomoniasis to include mild irritation to severe inflammation, burning, itching, redness or soreness of genitals; discharge can be thin, frosty, greenish, yellowish, clear or white with an unusual smell. The CDC (2016) stipulated that trichomoniasis cannot be diagnosed based on symptoms alone. A 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.
Diagnostic plan: Oligonucleotide probes test will be ordered and send out to an outside diagnostic lab company. Wet mount test, KOH/whiff test, and a 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 antibiotic therapy.
Metronidazole (Flagyl), 500 mg orally twice daily for seven days.
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 by a change in vaginal pH. Apple cider vinegar is a naturally 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 a natural disinfecting agent, and the patient will be directed to insert a tampon soaked with 3% hydrogen peroxide purchased at the drugstore, the goal is to eliminate bad bacteria in the patient body (Machado et al., 2015).
Yogurt will be recommended to the patient, and patiently 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 the patient will be instructed to add few drops of tea tree oil in warm water, stir the water and use the water to rinse the 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 naturally antibacterial and antifungal compounds. Furthermore, the patient will be instructed to eat raw or cooked garlic daily because of the garlic natural antibiotic properties. The rationale is to keep eliminate bad bacterial (Machado et al., 2015).
The 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, the patient will be educated to keep her vulva clean and dry. In addition, the 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, the patient will be educated to abstain from tight jeans, pantyhose with no cotton crotch, or clothing that traps moisture. Have only single-sex partners and use condoms (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 the 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. The patient will be scheduled 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’s diagnosis based on the available positive test results and clinical guidelines.