Week 3 Soap Note: Bacterial Vaginosis
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Week 3 Soap Note: Bacterial Vaginosis
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
June 17, 2016
Week 3 Soap Note: Bacterial Vaginosis
Patient Initials: WJ Age: 22 Gender: Female
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. 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.
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.
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. 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 heart murmur. Gastrointestinal: Denies abdominal pain, nausea, vomiting, or changes in bowel/bladder regularities. Admits good appetite.