Soap Note

Name: L.V

Date: 29th August, 2020

Time: 0900 Hrs

Age: 16 years

Sex: Female

SUBJECTIVE

CC: The patient reports of having vaginal bleeding and UCG, abdominal pain and pelvic pain with some unusual vaginal discharge 2 weeks after having unprotected sex.

HPI: The patient is G1P0 and is currently 4 weeks + 5 days pregnant by the last menstrual period (LMP) of 15/8/2020. She had home pregnancy test four days ago. She denies any nausea and is reporting a mild breast tenderness. She has vaginal bleeding and some unusual discharge following the unprotected sexual intercourse of two weeks ago. She reports of large amount of the yellowish to white vaginal discharge with no odor and she is currently wearing a pad. The discharge started one to two weeks ago. She never experienced any pain during her last sexual intercourse. There was no itching nor burning sensation. She denies of any previous discharge (Elwell et al., 2016).

Medications: She is under no medication at present

PMH: she denies the history of major illness, injuries, blood transfusion, or hospitalization. She is capable of performing her ADLs successfully.

Allergies: NKDA

Medication Intolerances: No medication intolerance

Chronic Illnesses/Major traumas: denies any history of chronic disease or major traumas. She has not been diagnosed with hypertension, diabetes, asthma, lung disease, Tuberculosis, or cancer.

Hospitalizations/Surgeries: denies any history of hospitalization or any surgical procedure

Family History: The mother is a live and has history of hypertension. Her maternal grandfather is having a history of adult-onset of diabetes mellitus.

Social History: she is living with her parents in a local community and she has no job. She has made an attempt to apply for the WIC and the Medicaid benefits last week after learning about her pregnancy. She is currently single with no man to specify as her boyfriend. She denies of any abusive environment (Witkin, Minis, Athanasiou, Leizer , & Linhares , 2017).

ROS

General: she denies fever, no reduction of weight, fatigue, or reduced appetite. She reports of having regular diet such as fruits and vegetables.

Cardiovascular: Denies palpitations or dyspnea on exertion

Skin: No bruises or rashes noted. No discoloration

Respiratory: no shortness of breath, cough, or congestion

Eyes: No use of corrective lenses, no blur, no change in the vision

Gastrointestinal: denies nausea, vomiting, and diarrhea.

Ears: No pain of the ear or loss in the hearing. Denies of ear discharge

Genitourinary/Gynecological: Denies frequency or urgency in urination or dysuria. There is vaginal discharge. No history of pap or mammo

Nose/Mouth/Throat: Absence of sinus issues, absence of discharges and nose bleeds, no dental illness, no throatiness, no throat pain, and no dysphagia

Musculoskeletal: abdominal pain and pelvic pain

Breast: mild breast tenderness

Neurological: No seizure, weakness, blackout out spells, or paralysis.

Heme/Lymph/Endo: the patient is HIV negative, no bruises, no history of blood transfusion, no night sweats, and cold or heat intolerance. She denies having swollen glands or increase in thirst.

Psychiatric: reports of no previous illness or depression. She denies of any sleeping

OBJECTIVE

Weight 54 BMI 20.3

Temp 97.5

BP 110/70

Height 163 cm

Pulse 60

Resp 18

General Appearance: she is alert, cooperating, well-nourished female with no distress, and is unaccompanied to the facility.

Skin: Brown, warm, clean and intact. No lesions or rashes.

HEENT: Head-normocephalic, atraumatic with no lesions. Even distribution of hair. Eyes: PERRLA and intact EOMs. There is no conjunctival or scleral injection; Ears-bilateral TMS, patent canals, and the visible landmarks; Nose-pinkish nasal mucosa, normal turbinate and no deviation of the septal; Neck-there is full ROM, supple. Throat-there is pinkish and moist oral mucosa, the pharynx is non-erythematous with no exudate. Teeth is in good repair.

Cardiovascular: there is regular rate and heart rhythm, no gallop or murmur, no tachycardia, pulses are 2+ ×4 ext.

Respiratory: There is symmetrical chest wall, regular and easy respiration, and lungs with clear to bilateral auscultation.

Gastrointestinal: non-palpable liver and spleen, no CVA tenderness, soft and non-tender abdomen, non-palpable fundus, rounded abdomen.

Breast: a mild breast tenderness with no masses or discharge. There is no dimple, wrinkle, and discoloration of the skin.

Genitourinary: The external genitalia WNL with no lesions. The speculum examination without smooth, dark pink, and nulliparous cervix. Heavy deposits of thicker light yellowish discharge with no odor. There are no adnexal masses that is palpable.

Musculoskeletal: Full ROM is seen in all the 4 extremities as patient is able to move about the examination room.

Neurological: Patient A & O × 3. The speech is having clear with good tone. She is having erected posture, stable with unchanged gait

Psychiatric: the patient is alert and oriented, maintain eye contact, responding to the questions in appropriate manner, and soft speech.

Lab Tests

Urine is positive for HCG, UA WNL with negative glucose, protein, and ketones

There is evidence of leukocytes under wet preparation, absence of trichomonas or clue cells, no hyphae.

Special Tests

KOH negative under whiff test

Diagnosis

Differential Diagnoses

False positive pregnancy test: the positive HCG is anticipated for patient on the HCG diet, molar, or ectopic pregnancy

Ectopic Pregnancy: patient denies pain and therefore, it is important to consider it in differential until there is positivity for IUP on sono

Sexually transmitted infection i.e. Chlamydia or gonorrhea: this is possible due to the higher amount of thicker and yellow discharge. There are no clue cells, hyphae or the trichomonas observed under wet preparation, and the unpredictable utilization of condoms and this is revealed by the positive pregnancy.

Diagnosis

Chlamydia: due to the larger amount of discharge and the vaginal bleeding.

Plan/Therapeutics

o Plan:

· Complete blood count (CBC) to help in the assessment for anemia; Urine CX due to the possibilities of the asymptomatic bacteriuria during pregnancy; Syphilis, HIV, and the Hepatitis B screening to help in the detection of the STIs that might be a risk to the fetal health; Gyn Probe for the G/C chlamydia to help in the detection of the sexually transmitted infection that can interfere with the well-being of the patient; ultra-sound to help in the confirmation of the IUP and the EDD; Rubella and the VZC titer to prevent the exposure of the fetus to the risk of the negative titer of the mother; and the blood type and the rhesus factors to help in determine the possible Rh incompatibility in case the mother is Rh-.

· Medication: Azithromycin 19 PO ×1; ceftriaxone 250 mg IM ×1, and the retest at the next visit.

· Education: The patient is educated to avoid sexual activity until seven days; patient is advised to make a call or return to the facility in case the symptoms fail to reduce; patient taught to avoid douches or other vaginal irritants; patient advised to plan for the prenatal care by visiting. The patient is advised to call the provider when she experiences the symptoms related to the bleeding, fever, contractions, serious or abrupt swell, and ROM. Patient is advised to have a healthy diet i.e. increase in the fruits and vegetables as well as lean protein. The patient is advised not to take soft or unpasteurized cheeses.

· Non-medication treatments: The patient can take garlic since it has antibacterial and the anti-inflammatory effects. It also has the antifungal properties that fight the growth of yeast which makes it beneficial during the antibiotic treatment for chlamydia (Wilson, 2019).

Evaluation of patient encounter: The patient is alert and well-oriented, but she has a concern about her vaginal bleeding and other symptoms that is presented in the facility. She is not well informed about her condition, therefore, requires both medical and education attention in the management of her condition.