Episodic/Focused SOAP Note Template

Patient Information:

Initials: C.B.

Age: 22 years

Sex: female

Race: African American

CC (chief complaint): burning with urination for 3 days

HPI: C.B. is a 22-year-old African American female, P0G0, who presents to the clinic with complaints of burning with urination for three days. It is associated with a vaginal discharge characterized by a fishy odor. She reports having unprotected intercourse with her new boyfriend. She denies any other partners besides him.

Current Medications: Multivitamin.

Allergies: No known food and drug allergies.

PMHx: Denies hypertension and diabetes. No previous hospitalizations.

Soc & Substance Hx: A college student. She is a social drinker. Denies tobacco and use of other recreational drugs.

Fam Hx: Her paternal grandfather is alive with prostate cancer, while her mother is alive with breast cancer in remission and hypothyroidism. Her father has hypertension as well as type 2 diabetes and hyperlipidemia. Her sister has type 1 diabetes, whereas her brother has no medical history.

Surgical Hx: No prior surgical procedures.

Mental Hx: History of anxiety and depression.

Violence Hx: No previous or current safety concerns.

Reproductive Hx: para zero gravida zero. Menarche at 15 years. The last menstrual period was on 5^th December 2022. Uses the Mirena IUD contraception. She is heterosexual. And reports unprotected vaginal sex with her new boyfriend.

ROS:

GENERAL: No fever, chills, weight loss, or fatigue.

HEENT: Eyes: No blurring of vision or double vision. Ears, Nose, Throat: No earache, hearing loss, sneezing, runny nose, or sore throat.

SKIN: No itching or rash.

CARDIOVASCULAR: No palpitations, orthopnea, chest pain, or peripheral edema.

RESPIRATORY: No cough, dyspnea, or wheezing.

GASTROINTESTINAL: No change in bowel habits, nausea, or anorexia.

NEUROLOGICAL: No dizziness, convulsions, headache, ataxia, or syncope. No changes in bowel and bladder function.

MUSCULOSKELETAL: She denies joint and muscle pains.

HEMATOLOGIC: She denies anemia, bruising, and bleeding

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No polyuria, polydipsia, or cold and heat intolerance

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

Physical exam:

VITAL SIGNS:  BP 132/6, P 62, Temperature 36.7 degrees Celsius, RR 16, Height 5’ 5” , Weight 148 (BMI 24.6).

GENERAL: A young adult African American female, appropriate for her stated age and in good general condition. She is slightly apprehensive. She is well-hydrated. No cyanosis, jaundice, pallor, lymphadenopathy, or peripheral edema.

HEENT: Normocephalic atraumatic head. Pupils equally and bilaterally react to light. Tympanic membrane intact. No nasal septum deviation. Moist and pink oral mucosa with no swellings.

NECK: No lymphadenopathy.

RESPIRATORY: Chest movies with respiration. Chest is clear to auscultation bilaterally, with normal respiration, rhythm, and depth upon exam.

CARDIOVASCULAR: Normoactive precordium. Point of maximal impulse in the fifth intercostal space in the midclavicular line. S1 and S2 heard. No murmurs.

ABDOMINAL: Non-distended abdomen that moves with respiration. No organomegaly. Tenderness in the suprapubic region.

GENITOURINARY: Examination of external genitalia reveals no ulcerations, redness, or other abnormalities of the skin, labia, introitus, or Bartholin glands. Cervix: firm, smooth, copious amounts of green discharge present. Uterus retroverted, mobile,  and non-tender. No adnexal masses or tenderness.

BREAST: Symmetrical breasts. No tenderness or masses in all the quadrants.

Diagnostic results: microscopic evaluation of vaginal fluid (wet mount) shows trichomonas (motile organisms).

Primary and Differential Diagnoses

Bacterial Vaginosis- Bacterial vaginosis is a condition that stems from the disruption of the vaginal ecosystem (Abou Chacra et al., 2021). C.B. presents with a greenish vaginal discharge with a fish odor as well as burning with urination. According to Abou Chacra et al. (2021), bacterial vaginosis is the commonest cause of abnormal vaginal discharge in women of childbearing age. Additionally, C.B. has risk factors for bacterial vaginosis, including sexual intercourse and the use of an intrauterine device.

Sexually Transmitted Infection- Unlike bacterial vaginosis, a sexually transmitted infection is caused by a source that is not endogenous to the vaginal flora. C.B. has a sexually transmitted infection, particularly trichomoniasis, as evidenced by microscopic findings of motile organisms (Van Gerwen & Muzny, 2019).

Additional clinical manifestations of trichomonas vaginalis include burning with urination, frequency, dyspareunia, thin frothy vaginal discharge with abnormal odor, vaginal itching, cloudy urine, and pelvic pain (Van Gerwen & Muzny, 2019). Similarly, C.B. has a history of unprotected sex with her new boyfriend.

Acute cystitis- implies bacterial infection of the bladder (Frazier & Huppmann, 2020). It is one of the most common infectious conditions in women. C.B. has features of acute cystitis, such as suprapubic tenderness and dysuria. Other features of acute cystitis include frequency, nocturia, hematuria, and urgency (Frazier & Huppmann, 2020). Furthermore, unprotected sexual intercourse is a risk factor for urinary tract infections. However, the presence of abnormal vaginal discharge and evidence of trichomonas on microscopy makes this diagnosis unlikely.

Investigations- Microscopic urinalysis and urine dipstick to exclude cystitis, which is a common cause of dysuria. Nucleic acid amplification testing (NAAT) for gonorrhoeaeand C. trachomatis, which are common and threatening sexually transmitted infections. Additionally, she requires blood tests for syphilis and HIV, which are also increased with unprotected sexual intercourse. C.B. has a significant family history of hypertension, diabetes, and hyperlipidemia. Consequently, random blood sugar, as well as a lipid profile, are essential to exclude these conditions. Finally, a pregnancy test is elemental to rule out pregnancy.
Medications- Metronidazole PO 500 mg twice daily for seven days (Verwijs et al., 2020). According to Verwijs et al. (2020), this regimen is effective for both bacterial vaginosis and trichomoniasis and increases lactobacilli, an important component of the vaginal flora. Other medications may be prescribed based on the laboratory results.
Education- C.B. will be educated on the importance of treatment compliance as well as the side effects of the medication. The patient should be advised to abstain from alcohol while taking metronidazole. Similarly, she will be educated on the risks of unprotected sex and associated STIs and offered education on safe sexual practices. Finally, C.B. should be educated on the importance of notifying her partner and having her partner seek treatment before another sexual intercourse (Van Gerwen & Muzny, 2019).
Referral- Currently no referral. Specialist consultation may be necessary in the case of resistance to metronidazole.
Disposition and Follow-up- The patient should be discharged on this medication, and a follow-up should be made to ensure that her partner is treated.

Reflection– having gone through this case. I agree with the preceptor’s diagnoses of bacterial vaginosis as well as trichomoniasis. This case highlights the importance of understanding the female reproductive system pathologies, particularly those related to abnormal vaginal discharge.

This case also provides a learning opportunity concerning obtaining a comprehensive history of sensitive matters related to sex and reproductive health. The case also outlines the importance of safe sexual practices. Given this case again, I would establish a good rapport and use open-ended questions to gather as much information as possible. Similarly, I will listen keenly and observe the patient’s body language. Finally, I will request for an opportunity to speak with the client’s partner.

References

Abou Chacra, L., Fenollar, F., & Diop, K. (2021). Bacterial vaginosis: What do we currently know? Frontiers in Cellular and Infection Microbiology, 11, 672429. https://doi.org/10.3389/fcimb.2021.672429

Frazier, R. L., & Huppmann, A. R. (2020). Educational case: Acute cystitis. Academic Pathology, 7(2374289520951923), 2374289520951923. https://doi.org/10.1177/2374289520951923

Van Gerwen, O. T., & Muzny, C. A. (2019). Recent advances in the epidemiology, diagnosis, and management of Trichomonas vaginalis infection. F1000Research, 8, 1666. https://doi.org/10.12688/f1000research.19972.1

Verwijs, M. C., Agaba, S. K., Darby, A. C., & van de Wijgert, J. H. H. M. (2020). Impact of oral metronidazole treatment on the vaginal microbiota and correlates of treatment failure. American Journal of Obstetrics and Gynecology, 222(2), 157.e1-157.e13. https://doi.org/10.1016/j.ajog.2019.08.008