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 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. Patient will be schedule 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 diagnosis based on the available positive test results and clinical guidelines .
References
Centers for Disease Control and Prevention. (2016). Genital/vulvovaginal candidiasis.
Retrieved from http://www.cdc.gov/fungal/diseases/candidiasis/genital/index.html
Centers for Disease Control and Prevention. (2016). Trichomoniasis. Retrieved from
http://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm
Machado, M., Castro, J., Palmeira-de-Oliveira, A., Martinez-de-Oliveira, J., & Cerca, N.
(2015). Bacterial vaginosis biofilms: Challenges to current therapies and emerging solution. Front Microbiol, 6, 1528-1542. doi: 10.3389/fmicb.2015.01528
Public Health. Bacterial vaginosis: Women’s health guide. Retrieved from
http://www.publichealth.va.gov/infectiondontpassiton/womens-health-
guide/bacterial-vaginosis.asp
Women’s Health. (2015). Bacteria vaginosis. Retrieved from
http://womenshealth.gov/publications/our-publications/fact-sheet/bacterial-
vaginosis.html
SOAP note rubric
| Subjective (15 points) | Points Possible | Points Earned |
| · CC | 1 | 1 |
| · Pertinent positives (OLDCARTS) | 5 | 5 |
| · Pertinent negatives & positives (from ROS) | 5 | 4 |
| · Pertinent PMH, SH, and FH | 3 | 3 |
| · Medications and drug/food allergies are included | 1 | 1 |
| Objective (15 points) | ||
| · VS including FHT if indicated | 3 | 3 |
| · Thyroid, Heart, and Lungs | 1 | 1 |
| · Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included. | -5 | 1 |
| · Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted. | -5 | 5 |
| · Diagnostic test results (ex; BHCG, CBC, Rubella, RPR, pap, GC, CT, 1 HR GTT, GC/CT, urine dip, wet prep, Blood group & RH Status) | 2 | 2 |
| Assessment (10 points for each priority diagnosis to equal 30) | 30 | 30 |
| Plan (15 points) | ||
| · Medications discontinued (“d/c lisinopril 10 mg daily”) | 1 | NA/1 |
| · Medications started (“start Ferrous Sulfate 325 mg daily”) | 2 | 2 |
| · Alternative therapies if appropriate (1 point) | 1 | NA/1 |
| · Diagnostic tests ordered with timeframe | 6 | 6 |
| · Referrals or consultations if appropriate | 2 | 2 |
| · Follow-up interval | 3 | 3 |
| Reflection notes (25 points) | ||
| · What did you learn from this experience? Any ah-ha’s? (5 points) | 5 | 0 |
| · What would you do differently? | 5 | 5 |
| · What additional data would you have gathered? | 5 | 5 |
| · What additional elements of the exam would you have done? | 5 | 0 |
| · Do you agree with your preceptor based on the evidence? | 5 | 5 |
| Total points | 100 | 85 |
Overall great work on your first SOAP note, please see comments.
�Great CC, clear concise in patient’s own words.
�Great use of OLDCARTS
�Great history
�Any fever, chills, fatigue?
�She
�Unnecessary
�Unnecessary
�Unnecessary in this case
�Unnecessary in this case
�Unnecessary in this case
�Unnecessary in this case
�Great
�Great choice, first line treatment for BV
�This may be beneficial in recurrent cases however besides fam hx, patient does not have any other risk factors, young, normal BMI.
�In The reflections you are to list What did you learn from this experience? Not addressed.
What would you do differently? You addressed this.
What additional data would you have gathered? You addressed this.
What additional elements of the exam would you have done? Not addressed
Do you agree with your preceptor? You addressed this.
See SOAP note template, even if you don’t have anything to add, just state that with the question.