Week 3 Soap Note: Bacterial Vaginosis Essay Assignment Paper
Week 3 Soap Note: Bacterial Vaginosis Essay Assignment Paper
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.
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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.Week 3 Soap Note: Bacterial Vaginosis.
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.
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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.Week 3 Soap Note: Bacterial Vaginosis.
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.
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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.
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