Episodic/Focused SOAP Note Template
Patient Information:
SL, 24yo, F, Caucasian
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S.
CC: Vaginal Bleeding
HPI: Susan Lang is a 24-year-old Caucasian female presenting to the clinic complaining of bleeding after intercourse. Susan relates she has been having some post-coital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies.
Current Medications:
Tylenol PRN fever
Midol PRN menstrual cramping
Allergies:
Denies medication, latex, and environmental
PMHx: Denies
Immunizations:
Childhood immunizations UTD
Last Tdap: 9-2022
Soc & Substance Hx: Cigarette smoking at a rate of ½ PPD since age 14. ETOH only on weekends, 6-8 hard liquor. Daily marijuana smoking.
She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen.
Fam Hx: Non-contributory
Surgical Hx:Denies
Reproductive Hx: Onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily.
ROS:
GENERAL: No weight loss, chills, weakness, or fatigue.
HEENT: Sore throat x 3 weeks.
HEMATOLOGIC: Post-coital bleeding x 6 weeks
LYMPHATICS: 1-2 day fever
GENITOURINARY/REPRODUCTIVE: Post-coital bleeding x 6 weeks
O.
Temp 97.8 oral, pulse 68, BP 112/64 sitting, height 5’6” and weight 118 lbs. BMI 19.04
HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened.
Lung: clear to auscultation
CV: regular sinus rhythms without murmur or gallop
Abd: soft, non-tender, liver normal,
Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.
VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
Cervix: friable, some petechia no cervical motion tenderness.
Uterus: mid mobile, non-tender
Adnexa: without masses or tenderness
Perineum: wnl
Rectum: wnl
Extremities: full rom, skin clear, no edema, reflexes 1+.
Neurological: CN II-12 grossly intact.
My differential diagnosis for this patient is cervicitis. Cervicitis is defined as inflammation of the cervix. Females diagnosed with this condition can present as asymptomatic or have complaints of pain during intercourse, vaginal discharge, and/or vaginal bleeding that occurs after intercourse or between menstrual cycles (Mau & Lewis, 2022). These symptoms usually occur from injury, inflammation, or irritation to the cells of the cervix (Mau & Lewis, 2022).
Additional questions I would ask this patient include:
What days did you develop a fever?
What was your temperature reading?
Is your sore throat constant or off and on? Is your throat pain worse with swallowing?
What is your partner’s gender?
How many partners are you currently sexually active with?
When was the last time you had sexual intercourse?
How many times in the past 6 weeks have you had sex?
What types of sexual acts do you participate in oral, vaginal, and or anal?
Have you ever been diagnosed with an STI? If so, when were you diagnosed? what was the diagnosis? What were your symptoms?
When were you last diagnosed with an STI?
Did you receive treatment?
When was your last menstrual period?
What symptoms do you experience with your menstrual period?
What is your normal menstrual flow?
Do you use pads and or tampons during your menstruation? How many do you use in a day?
What products or douches do you use in the vaginal area?
Are you having any pelvic pain?
Any vaginal discharge?
Any vaginal itching?
Are you experiencing any abnormal vaginal odor?
How many days do you bleed after intercourse?
How many pads do you go through after intercourse?
Is your bleeding bright red after intercourse?
Is intercourse painful?
Has your partner told you they are currently positive for any STIs?
Are you and your partner exclusive?
When was your last pelvic exam? What was the result?
When was your last pap smear? What was the result?
Any history of an abnormal pap smear?
Are there any toys or devices used during sexual activity? What are your cleaning practices for them?
What caused your delay in seeking care?
Testing
Based on the finding of the patient’s pelvic examination and history of present illness, I would obtain a urine pregnancy, perform a pap smear, and a pelvic ultrasound. I would also test the patient for sexually transmitted infections (STIs) including HIV, Trichomonas, oral and vaginal Gonorrhea, and Chlamydia. Additionally, I would recommend a Bacterial Vaginosis swab, yeast infection testing, testing for mononucleosis, streptococcus, and a complete blood cell count (CBC).
The patient is sexually active but is not on birth control. I would obtain a urine pregnancy test to rule out pregnancy. To rule out that the patient’s cervical bleeding is not related to the development of cervical cancers or human papillomavirus (HPV), I would perform a pap smear. This test looks for abnormal cells on the cervix that could lead to cancer (Penn & Berenson, 2019). I would order a pelvic ultrasound to evaluate the patient’s ovaries, cervix, fallopian tubes, uterus, and bladder. Additionally, I would order a transvaginal ultrasound to check the patient’s uterine walls and assess for polyps or fibroids that could be causing the bleeding (Xu & Xie, 2022).
The patient’s examination yielded a friable cervix, cervical petechia, and some yellow-in-color discharge. I would perform full panel STI testing to ensure she does not have a sexually transmitted disease causing her symptoms. According to Chlamydia, Gonorrhea, and Syphilis (2023), patients with an STI can present with abnormal vaginal bleeding, discharge, and or a friable cervix. I would also collect oral swabs on the patient to check for oral Gonorrhea and Chlamydia due to her complaint of a sore throat and bilateral anterior cervical adenopathy assessed on the exam. For her complaint of sore throat, I would also want to rule out mononucleosis and strep. Additionally, it is necessary to rule out the BV and yeast as the cause of the patient’s vaginal discharge therefore swabs would be obtained. The patient reports bleeding post-colloidal bleeding for six weeks. However, we do not know how frequently she engages in intercourse or how much bleeding she is experiencing; for this reason, I would also order a CBC to check her blood counts.
References
Chlamydia, Gonorrhea, and Syphilis. (2023). Www.acog.org. https://www.acog.org/womens-health/faqs/chlamydia-gonorrhea-and-syphilis
Penn, D., & Berenson, A. (2019, January 31). Pap and HPV tests | Womenshealth.gov. Womenshealth.gov. https://www.womenshealth.gov/a-z-topics/pap-hpv-tests
Mau, K., & Lewis, N. (2022). Evaluating Vaginal Discharge: Distinguishing Normal Physiological Discharge, Vaginitis, and Cervicitis. The Journal for Nurse Practitioners, 18(9). https://doi.org/10.1016/j.nurpra.2022.07.003
Xu, Y., & Xie, D. (2022). Prediction of Factors Associated with Abnormal Uterine Bleeding by Transvaginal Ultrasound Combined with Bleeding Pattern. Computational and Mathematical Methods in Medicine, 2022(1), 5653250. https://doi.org/10.1155/2022/5653250
Episodic/Focused SOAP Note Template
CASE STUDY #1
Patient Information:
CB, 22, F, Caucasian
S.
CC presents to the clinic today for burning and discharge for 1 week.
HPI: 22-year old Caucasian female presents to the clinic today for burning and discharge for 1 week. She states her boyfriend recently found out he was positive for chlamydia. She denies any other partners besides him. She is having a large amount of yellow watery discharge. Abdomen and uterus non-tender on palpation.
Additional questions to ask:
What does the discharge look like?
How is the consistency of the discharge? Is it in your underwear when you do to the bathroom?
Do you have any fishy smell?
Any pain when urinating or pain in pelvic area? If yes how bad is the pain on scale of 1-10?
Does pain radiate? Have you taken anything for the pain?
Have you taken any over the counter medicine for your symptoms?
How long ago was your partner diagnosed of chlamydia?
Have you ever been tested for STDs? If so have you ever been positive of an STD infection?
When was the last time you both were sexually active?
Have you ever had a yeast infection?
Current Medications: takes a multivitamin and LoEstrin daily for oral contraception
Allergies: NKDA
PMHx: Anxiety, Depression
Soc & Substance Hx: She uses social alcohol, but denies tobacco and any recreational drugs. She is employed at a local grocery store where she does have health, dental and eye insurance. Lives in an apartment in a nice neighborhood by herself with working smoke detectors in the home. Enjoys going to the gym after work to unwind, states she wears her iPods while driving so that she remains hand free and safe in the vehicle. Wears her seatbelt religiously
Fam Hx: mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia. Charlene has one brother with no medical history.
Surgical Hx:No surgical procedures.
Mental Hx:Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Denies any violent history or concerns.
Reproductive Hx: Menstrual history 06/01/2023 LMP, G0 P0, contraceptive use of LoEstrin oral pills she is in a monogamous heterosexual relationship with her boyfriend , types of intercourse include oral and vaginal. States she is concerned she has a STD from the yellow watery discharge she has experiencing and the burning to urinate.
ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: denies corrective lenses, no visual loss, blurred vision,
Ears: denies hearing loss
Nose: denies runny nose and sneezing
Throat: Denies sore throat
SKIN: Denies and rashes or skin itching
CARDIOVASCULAR: denies chest pain or pressure.
RESPIRATORY: Denies shortness of breath, cough, or sputum.
GASTROINTESTINAL: abdominal pain, nausea or vomiting, denies passing of blood.
NEUROLOGICAL: Denies headache, dizziness, syncope, numbness, or tingling in the extremities. Denies any change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: Denied and bleeding, or bruising.
LYMPHATICS: denies any swollen nodes, denies any history of splenectomy.
PSYCHIATRIC: denies history of depression or anxiety.
ENDOCRINOLOGIC: reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
GENITOURINARY/REPRODUCTIVE: states burning upon urination, yellow watery discharge for 1 week. States not Pregnant, G0P0. LMP: 06/01/2023. Denies breast issues, no lumps, pain or discharge noted. No reports of vaginal pain during sexually activity. States hasn’t had sex in 2 days due to the concern of a STD.
ALLERGIES: denies history of asthma, hives, eczema, or rhinitis.
O.
GENERAL: Awake, alert and oriented X4, sitting upright in chair
VITALS: BP: 132/68, HR: 62, Temp: 97.9, SpO2: 98, Resp: 18, Weight: 148 Height: 5′ 5″
HEENT:
Head: Normocephalic, atraumatic
Eyes: Vision 20/20, yellow sclera
Ears: Tympanic membrane grey midline, hearing intact
Nose: Pink and moist, no drainage noted
Throat: Pink and moist oral pharynx.
NECK/LYMP NODE- Trachea is midline, thyroid palpable and non-tender. No goiter.
Cardiovascular: S1/S2 present, no murmur, no ticks
PULMONARY- Equal chest rise and fall, Clear breath sounds throughout, no wheezing or crackles auscultated.
BREAST- No breast masses, tenderness, asymmetry, nipple discharge or axillary
Lymphadenopathy.
GASTROINTESTINAL- Abdomen is non-tender upon palpation. No distention. Abdomen is soft, flat and symmetric. No scars. No masses or nodules. Normal abdominal sounds throughout.
CERVIX- firm, smooth, yellow watery discharge in large amount present. No lesions.
VVBSU-Normally developed genitalia with no external lesions or eruptions. No cystocele.
UTERUS- RV, mobile, non-tender
ADNEXA- normal with no masses or tenderness. Normal ovary size
Diagnostic results:
Labs ordered: STD profile testing (CPT Code: 144027) (trichomonas, gonorrhea, chlamydia) Urinalysis (CPT Code: 81001), urine pregnancy test (CPT Code: 81025)
A.
Differential Diagnosis:
Primary diagnosis: A74.9 Chlamydia – symptoms of chlamydia causes burning when you pee, discharge from penis, vagina or rectum and may also have blood in your stool (Chlamydia, 2022). Based on the patient’s current complaint, it is most likely chlamydia especially with the fact that her partner is positive with chlamydia. The STD test and vaginal swab will give a definite answer as to if she has chlamydia or not. Chlamydia trachomatis is responsible for the greatest number of sexually transmitted infections and the majority of infection-related of blindness worldwide.(Mohseni, 2023).
B96.89 Bacterial Vaginosis- Patient is complaining of burning and vaginal discharge. Bacterial vaginosis is a condition caused by an overgrowth of normal vaginal flora. Most commonly, this presents clinically with increased vaginal discharge that has a fish-like odor. The discharge itself is typically thin and either gray or white. (Kairys, 2022). In this case she complains of yellow watery discharge.
B37.9 Yeast infection -is a possibility due to the copious discharge. With a yeast infection, the patient would also complain of itching in the perineal area, (Willems, 2020). Which in this case she is only complaining of burning.
Plan/Reflection:
Azithromycin 1g take once, followed by 500mg PO daily for 2 days. 0 refill, for Chlamydia infection
Fluconazole 150mg PO take one time 0 refills, if it is a yeast infection
If tests are done and it is found that patient has Bacterial Vaginosis, Metronidazole 500mg PO twice daily for 7days will be prescribed.
Patient is to follow up in a week for test results. Patient should abstain from having sex until fully treated, be sure that boyfriend has completed treatment as well, both need to be re tested prior to sex.
I would treat the patient for chlamydia pending the test results based on the history taken during the interview. The patient is currently sexually active with her boyfriend who appears to be infected with chlamydia, so it is most likely that she also has chlamydia. If the test come back and it is not chlamydia, I would have the patient stop the medication and we will put together a different plan based on the results of the test.
Health Promotion
Practice abstinence from oral, vaginal, and anal sex with a partner known to be infected until completely treated and re tested for negative results.
Encourage condom use even in “monogamous relationships” to prevent STDs.
Notify any recent sexual partner so they can be treated and prevent spread.
Educate that std’s can cause infertility, avoid douching, get regular pap smears and testing
References
Centers for Disease and Control Prevention. (2023, June 12).Chlamydial Infections. Center for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/chlamydia.htm
Links to an external site.
Centers for Disease Control and Prevention. (2022a, April 12).Chlamydia. Retrieved June 12, 2023, from https://www.cdc.gov/std/chlamydia/stdfact-chlamydia.htm
Links to an external site.
Mohseni M, Sung S, Takov V. Chlamydia. [Updated 2023 Jan 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537286/
Links to an external site.
Willems HME, Ahmed SS, Liu J, Xu Z, Peters BM. Vulvovaginal Candidiasis: A Current Understanding and Burning Questions. J Fungi (Basel). 2020 Feb 25;6(1):27. doi: 10.3390/jof6010027. PMID: 32106438; PMCID: PMC7151053.
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