Focused SOAP: Bacterial Vaginosis paper
Focused SOAP: Bacterial Vaginosis paper
Subjective Data
Chief complaint: “I have noticed an increase in vaginal discharge.”
History of presenting complaint: J.K is a 28years old female complaining of vaginal discharge and itchiness. The vaginal discharge is gradual from mild to moderate flow for three after engaging in unprotected sexual intercourse. It is associated with vulva vagina itchiness, lower abdominal pain during urination, and dyspareunia. She denies increased urinary frequency, urine incontinence, and urgency. Focused SOAP: Bacterial Vaginosis paper
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Reproductive health history: she had her menarche at the age of 15 years, a regular 28days cycle with a moderate flow for three days. She denies dysmenorrhea and premenstrual syndrome. She has two children born at term via spontaneous vertex delivery without obstetrics and post-partum complications. Her first sexual encounter was at the age of 18 years and has had multiple sexual partners. She has had recurrent urinary tract infections and sexually transmitted infections. She has a new partner who has been intimate for three weeks. Her last pap smear exam and routine breast examination are within normal limits.
Past medical history: the patient has had type 1 diabetes mellitus since the age of 20 years, recurrent urinary tract infections, and one episode of sexually transmitted disease (chlamydia infection). She recently had an upper respiratory tract infection treated with anti-histamine and antibiotics. She denies hospitalization and blood transfusion.
Surgical history: she denies major and minor surgical procedures
Allergies: the patient develops hives after taking amoxicillin. She denies food and environmental-related allergies.
Immunization: her immunization schedule is up to date. Her last tetanus and influenza vaccine was six months and three months ago, respectively.
Current medication: Lantus 12IU SC in the morning and 6IU SC in the evening.
Social history: JK is single and lives with her two children. She is in a new relationship with her boyfriend after breaking her from her two previous marriages. She works as a bartender, has studied up to secondary school, and is not attached to any religion. She enjoys traveling, swimming, and relaxing in her bathtub at home. She takes alcohol three times a week and smokes cigarettes and marijuana. She uses a safety belt when driving and has smoke detectors in her house.
Family history: she is the thirdborn in a family of four. Her parents are alive and healthy without a record of chronic diseases. Her grandparents have diabetes mellitus type 2. Her elder sister has diabetes and asthma. Her younger sister has diabetes mellitus type1. Her brother has no record of chronic diseases. She denies a family history of cancer and mental health diseases.
Review of systems
General: the patient denies fever, malaise, headache, weight loss, and sweating.
HEENT: she denies headache, throat pain, running nose, blurring of vision, and loss of hearing.
Respiratory system: the patient denies coughing, running nose, wheezing, sputum production, and tachypnea. Focused SOAP: Bacterial Vaginosis paper
Cardiovascular system: the patient denies dyspnea, chest pain, lower limb edema, orthopnea, and tachycardia.
Gastrointestinal system: the patient denies abdominal pain, reflux, heartburn, nausea, vomiting, diarrhea, and constipation.
Lymphatic system: she denies lower limb edema, frequent infections, fever, and fatigue.
Endocrine system: she denies heat intolerance, weight gain, irritability, skin hyperpigmentation, and swelling of the face.
Neurological system: she denies weakness of the muscles, tremors, facial droop, numbness, and tingling sensation.
Musculoskeletal system: she denies joint pain, previous fractures, muscle spasms, stiffness, and weakness.
Objective Data
General examination: the patient is alert and calm. She has no pallor, jaundice, cyanosis, and lymphadenopathy.
Vitals: blood pressure at 118/68mmHg, pulse rate at 78 beats per minute, temperature at 36.7 degrees celsius, and oxygen circulation at 99%.
Genitourinary system: the kidneys are palpable and non-tender. There is no flank and suprapubic tenderness. The external genitalia is normal with an erythematous mucosa. There is a grey discharge that is adherent to the vaginal mucosa. There is inflammation at the vaginal walls and cervix with grey discharge. There is no bruising, cervical motion tenderness, or fluid in the pouch of Douglas.
Respiratory system: there is symmetrical chest expansion with regular breath cycles. There is a resonant percussion note and vesicular breath sounds.
Cardiovascular system: the heart is palpable at the 5th ICS. The heart sounds S1 S2are present with no murmurs. Their peripheral pulses are present with normal volume, regular rate, and rhythm. There are no bruits.
Diagnostic investigations: vaginal swab for microscopy helps to determine the PH of the discharge and the bacteria present. Vaginal cultures and sensitivity help in determining the polymicrobial in the discharge.
Assessment
Differential diagnoses
- Bacterial vaginosis N77.1
- Vulvovaginal Candidiasis B37.3
- Cervicitis O86.11
Primary Diagnosis
- Bacterial vaginosis N77.1: Bacterial vaginosis is the inflammation of the vaginal walls due to the change or alteration of the normal bacteria in the vagina. It is common among women of reproductive age worldwide. More than a 21million women in the United States of America visit the hospital due to bacterial vaginosis. The presenting signs and symptoms are malodorous vaginal discharge, vulval irritation, dyspareunia, dysuria, and vaginal odor (Coudray, M. S., & Madhivanan, P. 2020). The risk factors are smoking, being single, induced abortion, smoking cigarettes, sexual activity with a new partner, douching, and recent antibiotics use. This is the primary diagnosis because the patient complains of vaginal discharge, vulvar itchiness, and dyspareunia. She has engaged in unprotected sexual intercourse with her new partner and recently took antibiotics due to an upper respiratory tract infection.
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Differential Diagnoses
- Vulvovaginal Candidiasis B37.3: is a fungal infection affecting the vulva and vagina. It presents with an erythematous vagina and labia associated with thick curdy-like discharge, dyspareunia, dysuria, vaginal soreness, and itchiness. It is a common infection in pregnant women, to diabetes mellitus, recent antibiotics intake, and weakened immune system (Swidsinski, et al, 2019). This is not the patient’s diagnosis despite having similar symptoms because she presents with a grey malodorous discharge. Vaginal candidiasis presents with white curd-like discharge. Focused SOAP: Bacterial Vaginosis paper
- Cervicitis O86.11: Cervicitis is the inflammation of the cervix presenting with mucopurulent vaginal discharge and induced vaginal bleeding. Causes are local trauma like the use of tampons, radiation, malignancies like cervical cancer, chemical irritation like douches, and infections like chlamydia or gonorrhea (Baithun, et al, 2018). Risk factors are multiple sexual partners, young age, single marital status, and alcohol use. The presenting symptoms are dyspareunia, vaginal discharge, genital burning, genital malodor, lower abdominal or pelvic pain, and abnormal vaginal bleeding. This is not the patient’s diagnosis because she denies vaginal bleeding, or genital burning, and does not have pelvic tenderness. Focused SOAP: Bacterial Vaginosis paper
