SOAP Note and Differential Diagnoses

 

Name:  M.B.

Date: 1/18/2017

Time: 10:00 am

Encounter ID: 3735664

Ethnicity: Caucasian

Age: 37

Sex: Female

SUBJECTIVE

CC:” I am here today for my well woman examination and possible bacterial vaginosis”

HPI:

M. B. is a 37 years old female who has many years of a history of bacterial vaginosis and HSV. Pt was treated 2 month ago for BV with Clindesse vaginal inserts and Metronidazole 500mg for 10 days.  After cultures obtained + bacteria ureaplasma noted and treated with Z-pack as directed. Pt reports some improvement. Recently the patient has started to have strong vaginal odor with clear to whitish discharge that started back up 2 weeks ago after sexual encounter with monogamous partner. Patient denies dysuria, nausea, vomiting, or abdominal. Pt also denies dyspareunia.

 

Medications: (list with reason for med)

Valcyclovir 500mg oral QD, probiotics tablets daily

PMH: HSV, hemorrhoids and colon polyps, bacterial vaginosis, heart murmur

Allergies: NKDA     Medication Intolerance:  None

Chronic Illness/Major traumas: None

Chronic Health Problems: HSV, bacterial vaginosis

Hospitalizations/Procedures: hemorrhoidectomy, polypectomy, C-section, right wrist ganglion cyst removal, right ACL repair, tonsillectomy. Patient denies any recent hospitalization.

Family History: 

Father: bipolar, TIA, MI, DM

Mother: depression, anxiety, HSV, chronic kidney stones

Siblings: brother ADHD

Grandparents: unknown

Social History:

Occupation: licensed massage therapist

Marital Status: pt lives with long term male partner

Children: 4-year old son with unspecified immune disorder

Birth control: Condoms

Exercise: Pt does yoga, jogging, and running approx… 3-5 days week

Tobacco Use: hx smoking ½ pack per day. Quit 10 years ago

Alcohol Use: occasional alcohol (once monthly)

Substance abuse history: pt reports cocaine and marijuana socially during college years only

Safety assessment: Feels safe in home environment

ROS

General

Denies any fever, fatigue, night sweats, or recent weight gain or loss.

Cardiovascular

Denis any chest pain, bruits, palpitations or edema. Pt stated she has a history of heart murmur

Skin

Denies any bruising or cuts to skin.  Denies any abnormal nail or hair growth. c/o of bump to upper mid back (followed by dermatology). C/o of fungus to all toenails.

Respiratory

Denies any cough, wheezing, dyspnea, hemoptysis, SOB, or exposure to tuberculosis.  No history of pneumonia.

Eyes

Denies any pain, visual changes, blurring, redness or flashing lights.  Pt does not wear glasses or contact lenses.

Gastrointestinal

Denies constipation, nausea, vomiting, diarrhea, black or tarry stools or blood in stools.  Denies dysphagia. Denies any abdominal pain or heartburn. Patient had polyps in her colon. Last bowel movement yesterday.

Ears

Denies discharge, ear pain, vertigo or hearing loss.

Genitourinary/Gynecological

Denies any urgency, frequency, nocturia, dysuria, hematuria.  Pt complaint of vaginal discharge, stated sometimes the drainage is clear or white, the discharge has strong odor, sometimes a fishy odor, she described like occasional she can smell odor even after she take a shower. She has tried multiple over the counter remedies and has been treated by the provider multiples times. No irregular or missed menses, normal flow. 26- 28 Days between menses, Length of menses 5 days, Quality of flow: heavy at the beginning then light. Last pap 2016- normal. Gravida 1, Para 1, Abortion 0.  LMP: 12/31/16

Nose/Mouth/Throat

Denies mouth or throat pain, hoarseness, and dryness.  Denies any use of dentures.

Musculoskeletal

Denies any back pain, joint swelling, osteoporosis or fractures, crepitus or any decreased in ROM. Denies any joint pain.

Breast

Denies any lumps, or changes.  Perform breast exam but not consistently.

Neurological

Denies syncope, vertigo, seizures, focal weakness, numbness, paresthesia, gait instability, falls, lightheadedness, head injuries or memory loss.

Heme/Lymph/Endo

Pt denies easy bleeding, increased bruising, or difficulty clotting.  Denies lymph node tenderness or swelling. Denies increase hunger or thirst, hot or cold sensations recent gain or loss weight or change in body hair, no night sweats.  Denies history of DM and hypothyroidism.

Psychiatric

Denies any sleeping difficulties. Sees psychotherapist for energy healing therapy.

OBJECTIVE

Weight 128 lbs      BMI 25.4

Temp 97.7 Orally

BP 112/68

Height 4’11”

Pulse 82

Resp 18

General Appearance

The patient is a well-nourished, well-developed. 37-year-old Caucasian female in no acute distress. She is in a pleasant mood, dressed and groomed appropriately.

Skin

Skin clean, dry, intact and warm to touch.  No bruising noted.  No cyanosis or clubbing noted. Skin turgor normal. No redness or rashes noted.  1 cm raised brown and oval nodule noted. (Followed by dermatologist)

HEENT

Head:  Head is normocephalic, no tenderness over frontal an maxillary sinuses with palpation.  Hair appears well distributed and healthy.  No bald spots noted.  Occipital area no tender to touch.

Eyes: Sclera white, conjunctiva pink.  No drainage or redness noted. Extraocular muscles test normal, corneal light reflex normal and PERRLA examination normal.

Ears: Bilateral tympanic pearly grey with positive light reflex.  Both ear canal patents.

Nose:  No septal deviation noted.  Nasal mucosa pink, normal turbinate

Throat: Patient has all her teeth in good condition.  Oral mucosa pink and moist. Tonsil absent, lesions, redness or exudate noted, no inflammation of epiglottis noted.   Mucus membranes moist.

Neck:  No lymph nodes palpable or tenderness noted.  No thyromegaly or nodules noted.  Full range of motion with no pain.

Cardiovascular

S1, S2 with regular rate and rhythm noted during auscultation.  No S3 or S4 noted.  No extra sounds, clicks, rubs or murmurs noted.  Regular and strong bilateral carotid pulses with no bruits noted.

Peripheral Vascular: Capillary refill 2 seconds.  Bilaterally 2+ radial pulses.

Respiratory

Symmetrical chest expansion.  Respiration 16/min, regular and easy.  By auscultation bilateral lung sound clear on inspiration and expiration.  No crepitus or adventitious sounds noted.  No shortness of breath.

Gastrointestinal

Bowel sounds present in all 4 quadrants.  Abdomen soft and no distended. No hepatosplenomegaly or masses palpable.

Breast

Symmetrical bilaterally. Soft (diffuse fibrocystic texture) and smooth, no dimpling, no masses or lumps. Upon palpation breast, non-tender, smooth, and without masses. No nipple discharge. The contour and overlying skin is normal. Axilla: palpation of the lymph nodes in the axillary region does not reveal any abnormal enlargement.

Genitourinary/Gynecological

External genitalia without erythema, lesions, or masses. Vagina rugae. Non-Homogenous discharge. Urethral meatus is without prolapse and the urethra is without scarring. There is no bladder tenderness; there is no dullness to percussion at the region above the symphysis pubis. Vaginal mucosa is pink and without discharge. There is no cystocele or rectocele. Cervix os is normal. Bimanual exam: uterus retroverted. No adnexal masses or tenderness. No cervical motion tenderness. Inguinal: palpation of the lymph nodes in the inguinal region does not reveal any abnormal enlargement.

Musculoskeletal

Full ROM in all extremities.  No swelling, joint pain, bruises, cyanosis or crepitus noted.  Great deep tendon reflex of patella.  Patient walked around the room, steady gait noted.

Neurological

Great coordination and steady gait.  Speech clear and answer questions appropriately.

Psychiatric

Pt alert and oriented to person, time, place and situation.  Cooperative and maintains eye contact.

Lab Tests

UA done in office today

Color: yellow Clarity: clear

SG=1.010, pH=7.0, Leu=NEG, Nit=NEG, Pro= NEG, Glu=NEG, Ket=NEG , UBG=0.2 , Bil=NEG , BLD= NEG.

 

Pap Smear done in office today as well as cultures:

 

– Pap – results pending

-Gonorrhea and chlamydia – results pending

-Mycoplasma HOM/UREA culture –results pending

-VAG path3- results pending

 

Blood drawn:

CBC, CMP, TSH, Vit D level, lipids – pending

Special Tests

None

 ASSESSMENT FINDINGS AND PLAN

Differential Diagnosis:

1.      Encounter for gynecological examination (general)(routine) without abnormal findings (Z01.419)

2.      Acute Vaginitis (N76.0)

3.      Vaginal Candidiasis, unspecified (B37.9)

4.      Other nail disorders (L60.8)

Plan:

·         Diagnosis: Encounter for gynecological examination (general)(routine) without abnormal findings (Z01.419)

·         Further Testing: Cultures sent to lab- treatment plan to follow after cultures results

·         Medication: None

·         Education: Increased water and low calorie (powerade for electrolytes) intake to at least 64 oz daily this would help to clean the urinary system and maintain electrolytes balance, encourage patient acceptance of natural vaginal odor, no additional antibiotic treatment warranted at this time.

·         No medication treatment: Soak in Epsom salt at least 3 times a week.

·         Return to office:  Follow up in one year and as needed. Results will be called to patient.

Plan:

·         Diagnosis: Other nail disorders (L60.8)

·         Further Testing: None

·         Medication: Penlac topical BID x 3 months

·         Education: Patient educated to keep toe nails free of nail polish, keep toes and nails dry and open to air as much as possible, don’t share shoes and instructed patient to continue medication for 3 months since it can take a long-period to clear. Patient prescribed with Penlac topical BID x 3 months. Follow up in 3 month for toenails re-evaluation and as needed.

·         No medication treatment: Soak in Epsom salt at least 3 times a week.

·         Return to office:  Follow up in 3 month for toenails re-evaluation

Evaluation of patient encounter: Patient allowed me to be in the room with the provider during her visit. Performed complete physical examination, pap smear, bimanual examination and cultures. Presented patient to provider, I have missed some important details during the interview process with the patient.  Will continue to practice and improve.

 

 

 

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