Bacterial Vaginosis Soap Note #3 NUR 775

ICD-10 Diagnosis Codes

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Clinical Notes

SUBJECTIVE DATA (S)

Source of History: the patient is the main source of history. She appears to be reliable.

Chief complaint (C/C)

“I experience vaginal itching in the past one week and I noticed gray discharge with a bad smell. The itching worsened about two days ago”.
History of present illness (HPI)

The patient is a 22-year old African American female who presented to the clinic complaining of vaginal itching that began a week ago. A few days later, she noticed a grayish vaginal discharge with a strong foul odor. The smell was particularly strong after she had sex with her boyfriend.

The patient also described experiencing a burning sensation when urinating and chose to seek medical help because she could no longer tolerate the discharge, foul smell, or odor. The itching is aggravated by sex and relieved by having a sitz bath. She has not tried other therapies or treatments. The patient denies having chills, fevers, nausea, or vomiting. She is in a monogamous relationship with her boyfriend of one year. They always use condoms because she is not on any form of birth control.

Past History

Childhood Illnesses: no major childhood illnesses.
Adult Illnesses: No major adulthood illnesses
Psychiatric illnesses: Denies any psychiatric illnesses in the past and present.
Accidents and injuries: Denies any injuries or accidents.
Operations: None
Hospitalizations: None
Current medications: None
Allergies: No known allergies.

Social history

Tobacco: Denies tobacco use in the past or present.
Alcohol: Drinks socially at most once a week.
Drugs: Denies past or present illicit drug use (If history positive- amount and duration).
Sexual history: Heterosexual and in a monogamous relationship with her boyfriend of one year. She always uses condoms.
Marital status: Single. Describes her relationship as satisfactory. Denies any pregnancies.

Living situation: Lives in her college dorm and with her parents during school breaks.
Work: Part-time waitress in a restaurant near campus.
Education: Bachelor’s degree in computer science.

Screening tests

– Dental exam: no cavities or decay (05/2021).
– Eye exam: Vision 20/20 both eyes (08/2020).both eyes)

-Last pap smear 11/2020- normal

-HIV test- 10/2020-negative

Immunization

– Influenza vaccine: 11/2020

Family history

Maternal grandmother: type 2 diabetes. Age 75. Living
Maternal grandfather: Medical history unknown. Deceased at age 72.
Paternal grandmother: Hypertension. Age 84. Living
Paternal grandfather: Medical history unknown. Deceased at age 60.
Mother: no major health issue. Age 46. Living.
Father: no major health issue. Age 51. Living.
4 siblings.
No children.

Review of Systems

General: Denies changes in weight or sleeping pattern, chills, fever, or body aches.
Skin: Denies presence of rashes, nodules lesions, dry skin, hair loss, or brittle nails.
Head: Denies headache or head injury. No Lightheadedness or dizziness.
Eyes: The patient has good vision and her last eye exam was on August 2020. 20/20 vision, has never worn eyeglasses or contacts. Denies vision changes, eye pain, blind spots, flashing lights, cataracts, or glaucoma.

Ears: Denies any hearing problems. No history of ear infections, aches, vertigo, or discharge.
Nose and sinuses: denies any recent colds. No history of nasal discharge, stuffiness, hay fever, nose bleed, sinus problems. Denies any changes in sense of smell.
Mouth and throat: no cavities or stains on teeth as indicated by the last dental visit five months ago. Denies mouth sores, bleeding gums, changes in taste, or sore throat.
Neck: denies neck stiffness or pain, tenderness, neck injury, or swelling.

Breasts: Denies any pain, discomfort, lumps, or nipple discharge. Examines her breast regularly.
Respiratory: Denies cough, wheezing, difficulty breathing, or dyspnea. Has no history of asthma, pneumonia, bronchitis, tuberculosis, or any other respiratory problems.
Cardiac: denies chest pain, palpitations, shortness of breath, arrhythmias, edema, or heart murmurs. No history of hypertension.
Gastrointestinal: denies abdominal pain, vomiting, nausea, changes in bowel movements, appetite changes, or any bladder irregularities.
Urinary: admits to feeling a burning sensation when urinating. Denies blood in urine, back pain, changes in frequency of urination. Denies history of urinary infections, incontinence, or kidney stones. Denies any history of sexually transmitted infections.
Genital: patient began her first period at age 12 and they occur regularly every month for four days. Mild bleeding during periods with mild cramping. The patient had her last period three weeks ago. Admits vaginal itching that became more severe in the past two days.

Reports gray discharge with a strong odor; fishy vaginal odor after sex; no history of STDs. No pregnancies, does not use contraceptives, condom is the main birth control method. Patient is a heterosexual female in a monogamous relationship with her boyfriend of one year. There are no concerns about HIV.
Peripheral vascular: denies history of clots in the veins, varicose veins, edema, leg cramps, or sensitivity to weather changes.
Musculoskeletal: Denies joint stiffness or pain. Full range of motion in all joints.

Neurologic: denies dizziness, memory loss, seizures, falls, numbness or tingling, fainting, changes in orientation, judgment, or insight; no history of paralysis or involuntary body movements.
Hematologic: denies bleeding or clotting disorders, lymph node swelling, anemia, previous blood transfusions, or family history of hemophilia.
Endocrine: Denies intolerance to cold or heat, thyroid problems, changes in hunger, thirst, excessive sweating, or changes in shoe or glove size.

Psychiatric: Denies any mood changes, depression, anxiety, suicide ideation, or suicide attempt. No history of psychiatric illnesses.

OBJECTIVE DATA (O)

General survey: Alert and oriented x 3. Appears well-groomed. Does not seem to be in any form of distress. Appears younger than age 22 due to short stature and small build.
Vital signs: T 98.6 ºF, P 90, RR 18, BP 117/76 (left arm, sitting, automatic), oxygen saturation 100 % room air, height 5 ft. 0 in., weight 105 lbs. BMI 20.5

Skin: Skin is warm and moist and demonstrates normal turgor. There is no evidence of ulcers, lesions, rashes, or bruising. Hair: long, thick, and curly with no hair loss. Nails: no clubbing, pink with capillary refill < 2 secs.

Head: Normocephalic, no bumps, lesions, injury, or nodules noted. Clean scalp with no tenderness, lumps, or lesions. Symmetrical face.

Eyes: Vision 20/20 in both eyes. Clear sclera and conjunctiva. Full visual fields, sharp disc margins with no hemorrhage, exudates, papilledema, cotton wool spots, or AV nicking.

Ear: clear ear canals, no edema or lesions in external ear, good acuity to whispered voice, tympanic membrane visualized.
Nose and Sinuses: moist mucosa, intact nasal septum, nares patent with no discharge, normal turbinates, sinuses non-tender on palpitation.
Mouth and throat: pink and most oral mucosa, no lesions, no cavities on teeth, pink gums with no lesions, bleeding, redness, or swelling. Intact tongue, midline, tonsils have no swelling, exudates, or redness. Uvula midline, no exudates or erythema in the larynx.
Neck: thyroid supple. Midline trachea, no lymphadenopathy or thyromegaly.
Back: Full range of motion, no deformities, tenderness, swelling, or ecchymosis in the spine.
Anterior/Posterior thorax and lungs: symmetrical with no retraction or deformity. Chest expansion is equally bilateral. RR is 18 per minute. No evidence of tenderness during anterior and exterior chest palpation. No wheezing, crackles, or rhonchi.

Breast, axillae, and epitrochlear nodes: Breasts are symmetrically bilateral with no tenderness, mass, discharge, or nipple thickening, everted nipples. Epitrochlear and axillary nodes are non-palpable.

Cardiovascular system: Normal S1 and S2. No murmurs, rubs, gallops, S3, S4, or heaves.
Abdomen: Soft, non-distended, non-tender. No hepatosplenomegaly. Present bowel sounds in all four quadrants. Non-palpable kidneys and spleen.

Genital: vaginal discharge noted, thin and grey. Foul fishy odor noted. No swelling, redness, or rashes around the vagina and vulva.
Rectal: The patient declined the rectal exam.
Peripheral vascular system: Radial, ulnar, brachial, posterior tibial, dorsalis pedis, and poptilial pulses brisk (2+) bilaterally. Legs have no evidence of temperature change, swelling, cyanosis, rashes, or varicose veins.
Musculoskeletal: Muscle strength and tone 5/5 bilaterally. Full range of motion in both upper and lower extremities, normal gait, and station. No tenderness, deformities, atrophy, effusion, crepitation, or masses.
Neurologic system: coherent thought patterns, fully oriented to time, person, and place. Clear and audible speech. Movable extremities. Two-point discrimination and touch sensation are intact. Normal reflexes, (2+) bilaterally for triceps, biceps, patellar, brachioradialis, plantar, and Achilles.

ASSESSMENT (A)

Diagnosis: Bacterial vaginosis

Bacterial vaginosis is caused by bacteria overgrowth in the vagina and is the most common cause of the offensive foul smell and abnormal discharge among women within the childbearing age. Although most women are asymptomatic, common symptoms may include foamy or watery discharge with a foul odor, irritation and itchiness in the vagina, and burning sensation during urination (Jones, 2019). The patient exhibited all the symptoms of bacterial vaginosis hence all diagnostic tests should focus on clarifying the condition.

As per Redelinghuys et al. (2020), the main tests for bacterial vaginosis include the wet mount test, whiff test, vaginal examination, and vaginal pH test. Vaginal examinations confirm the presence of abnormal discharge and rule out other symptoms such as swelling and redness around the vulva.

The presence of clue cells in the wet mount test establishes a bacterial vaginosis diagnosis. Whiff test assesses for fishy odor and a positive test illustrates abnormality and confirms fishy odor. Vaginal pH test helps to detect abnormalities in pH balance.

Differential diagnoses:

– Vaginal candidiasis

This is a common yeast infection in the vagina that is caused by the fungus candida. The main impacts include swelling, itching, and irritation that are usually indicated by various symptoms including odorless thick white discharge, burning and pain during sex, and rash around the vulva (Yano et al., 2019). The patient had no rash and her discharge was greyish with a foul smell hence vaginal candidiasis was ruled out as the main diagnosis.

– Trichomonas vaginalis

Trichomonas vaginalis is a sexually transmitted infection. The main symptoms include burning, redness, itching, or soreness of the vagina, thin discharge that may be yellowish, white, clear, or greenish with a foul smell, and discomfort when urinating (Barbosa et al., 2020). Trichomoniasis was not selected as the main diagnosis since the patient’s discharge was grayish with no frosting. The patient did not have any redness around her genitals.

PLAN (P)

A. Diagnostic:

1.      Urine dipstick: negative

2.      Vaginal examination: indicated thin grayish watery discharge with a foul odor.

3.      Wet mount test: Clue cells present.

4.      Whiff test: positive, characteristic fishy odor

5.      pH: 5.2

6.      pregnancy test: negative

B. Medication management:

– Metronidazole 500 mg administered orally twice daily, 7 days. Verwijs et al. (2020) demonstrated in a study that metronidazole is an effective intervention for bacterial vaginosis especially among patients with no history of STIs.

C. Referral: None

D. Patient/family education (including follow-up):

1.      Educated patient on the importance of wiping from front to back to avoid bacterial transfer from the rectum to the vagina.

2.      Advised patient to refrain from using strong soaps or feminine sprays on her vagina.

3.      Advised patient to stop wearing tight jeans or underwear without a cotton crotch. As per Vodstrcil et al. (2021), tight clothing prevents air movement around the vagina and increases the risk of more bacterial growth.

4.      Encouraged patient to continue using a condom during sexual intercourse.

5.      Advised patient to avoid taking alcohol since according to Verwijs et al. (2020), alcohol can result in severe side effects including palpitations, headache, stomach pain, and hot flushes.

6.      Advised patient to come back if there is no improvement after a week.

7.      The patient verbalized knowledge and understanding of the information given.