SOAP NOTE
SOAP Note on Pelvic Inflammatory Disease
Name xxx
United State University
Course xxx
Professor xxxxx
Date xxx
SOAP Note on Pelvic Inflammatory Disease
ID:
Client’s Initials: G.H, Age: 23, Gender: Female, Race: Caucasian American, Date of Birth: January 01, 1999.
Subjective Data
CC: “I have vagina discharge, pelvic pain, and fever.”
HPI: Ms. G.H was accompanied by her boyfriend to the clinic. She reports having vaginal discharge that is malodorous, pelvic pain, and fever. She also complained of vaginal itching, and she also experienced a burning pain when urinating. She has experienced the pain for the last two weeks, and she described the rate of pain as 6/10. She experiences pain every time she has sex. However, she does not report changes in urinary regularity or persistency, hesitancy, recurrence, polyuria, or reduced urine stream. She has not used any medicine or treatment since the onset of pain. The symptoms started eight days ago. She is sexually active and describes having sex three weeks ago. She does not report any history of sexually transmitted diseases.
Past Medical Records: No major chronic diseases but has had mild flu, treated by home remedies such as ginger.
Surgery: No medical surgery.
Family History: She has a boyfriend. Her father is a retired military officer and smokes 1 pack of cigarettes a day, had a history of hypertension at the age of 45. Her mother is a retired teacher and has never had a serious chronic illness. She has two siblings, a brother 20 years old and a sister 15 years old. Both are in good health.
Social History: She is a college student. She goes to school from Monday to Friday and spends the weekend with friends and her boyfriend. She does not use hard drugs, nor does she smoke a cigarette. She does not drink alcohol. She lives alone in an apartment, which she says is safe.
Review of Systems
Constitutional: G.H is a Caucasian female adult with severe signs of physical affliction. She describes a moderate fever and reduced energy levels although, she denies chills, sweating at night, anorexia, and weight gain or loss.
Head: She has not encountered headaches, has not lost consciousness and has no numbness.
Eyes: She claims that there is no vision alteration, no need for eyeglasses, she has no eye ache, no redness, no glaucoma, no inflammation, blurred vision, and she has no abnormal tears in her eyes.
Ears: She does not have a hearing defect, no ringing, no fungal infections, no discharges, no aches, and she does not wear hearing aids. She does not wear hearing protection.
Nose: There is no nasal congestion or runny nose, and she does not have redness and swelling in his nose, no nosebleeds. She also does not have soreness, and she has a normal smell.
Mouth: She has no growths in the mouth, no lesions, no bleeding gums, no ulcers, no tooth illness, no mouth irritation, no dried lips, and no tumor on the tongue. The taste is normal.
Throat: she feels a sore throat and has trouble swallowing especially solid meals.
Neck: she does not have any stiffness, meningeal symptoms, or suppleness; she also does not have any bruits.
Skin, Hair, and Nails: According to the patient, she has not had any rashes, also she no changes in skin tone. She has no abnormalities in hair color or nails.
Cardiovascular: She has no vibrations, she has no chest pain, no breathlessness, no congestion, she has no heart sounds, no anemia, orthopnea.
Integumentary and Breast: She has no inflammation, lesion, or rash. She has no lumpiness.
Gastrointestinal: Has regular bowel habits. She has no nausea or vomiting, no diarrhea or constipation, no loss of appetite, no gastrointestinal ulcers or heartburn, no stomach cramping or inflammations, no dysphagia, and has no hematochezia
Genitourinary: She denies urine urgency, has no dysuria, and normal urine frequency.
Musculoskeletal: There are no joint pains, she has no inflammations, no bruises, no muscle cramps, no disk failure, no backaches, no arthritis, and the body parts move normally.
Neurological: She does not have headaches, no head traumas, no seizures, no infections of the brain; she has not had a loss of memory. She does experience fainting, epilepsy, tremor, or paralysis.
Psychiatric: There have been no suicide attempts, she is not depressed or facing anxiousness, she has no memory alteration.
Allergies: There are no documented drug allergies or food sensitivities, and she not allergic to pollen or animal fur.
Objective Data
Vital Signs
Temperature: 37.4℃ Height:176 cm Weight:55 BP:124/72, RR: 19 SpO2: 99% Pain: 70% in the pelvic BMI: 17.8
Physical Examination
Constitutional: She is attentive, friendly, and healthy-looking.
Head: Her head shape is Noncephalic. She has thick hair that is evenly scattered across the scalp.
Eyes: Her eyes are free of edema, and the cornea is completely clear. She has a sharp vision. She does not wear contact lenses to get a clear vision.
Ears: On examination, she has no swellings and no hearing deficiency.
Nose: She does not have a discharge from the nose, no swellings, no sinus deviation, no splenic tenderness.
Mouth: She does not have gum disease. No lip wounds, no tongue swellings or wounds. The dentistry formula is in the normal range. She has no erythema or discharge in the oropharynx. Mucosal membranes are moist. Also, the tonsils are neither swollen nor enlarged.
She has a moist oropharynx and erythema, and white exudate on her tongue. Tonsils are divided into four quadrants bilaterally.
Neck: In the trachea, there are no tumors, and it is located in the middle. Neither cervical nor axillary lymph nodes nor supraclavicular lymph nodes may be seen in the neck region. There are no nodules or hyperplasia in the thyroid glands.
Lungs: Breath sounds normal, and there are no wheezes, crackles, or coughs. No dyspnea
Cardiovascular: There are no chest murmurs, chest discomfort, or palpitations that have been observed. It was noted that S1 and S2 were present. Respiratory action that is not laborious and even. There were no signs of coughing or wheezing. No hiccups
Abdomen: There is bilateral abdominal and pelvic pain noted.
Musculoskeletal: The strength and tone of the motors are normal. Extremities are normal; there is no cyanosis.
Genitourinary/Gynecological: The bladder is not swollen, and her Genitalia is shaved. There are no vulvar lesions and vagina is well estrogenized. The vaginal wall has no lesions and is well rugated. A stinking smelly vaginal discharge which is thick cloudy is noted. She has a pink, sturdy, and nulliparous cervix.
Skin: She has no skin rashes, no wounds, no lumps, and no lesions. Her nails have no deformities.
Psychiatric: She possesses exceptional decision-making abilities. Mood and attitude are normal, and she is lively and alert. Memory recall from the present and the past are both good.
Assessment
Differential Diagnosis
Pelvic inflammatory disease N73. 9- These are infections of the reproductive system in females. The infections often occur when the bacteria transmitted sexually spread into the other reproductive parts from the vagina (Safrai et al., 2020). Fever and pelvic pain are the most common symptoms. Vaginal discharge may occur. This was the primary differential diagnosis as the patient explained the symptoms.
Chlamydial infection A74.9 is a sexually transmitted disease that does not always cause symptoms and is very common. Chlamydial is most common in women, although it affects people of all ages. Many people infected with chlamydia do not evolve symptoms, but sexual contact can transmit it to others. Symptoms comprise genital pain and vaginal and penile secretions (McQueen et al., 2020). Antibiotic therapy is recommended for affected patients and their sexual partners. This was excluded because the urine test was negative.
Gonococcal infection A54. 9. A sexually transmitted disease that can lead to infertility if left untreated. Regular screening helps identify cases where the infection is present even in the absence of symptoms (Cyr et al., 2020). Symptoms include painful urination and abnormal secretions from the penis or vagina. This was excluded because the nucleic acid amplification test was negative.
Plan
Diagnostics
Pelvic Exam: To exam the patient pelvic organs
Complete blood count (CBC) with differential: WBC: Elevated.
Quantitative beta-HCG to rule out pregnancy
Pelvic ultrasonography-An ultrasound scan is a medical examination that involves the use of sound waves of very high frequency to take a live picture of the internal organs. It is also referred to as sonography (Savaris et al., 2020). This test helps assess the likelihood that a patient will have a pelvic inflammatory disease.
Urine test– Urine checking testing is presently mostly used to locate bacterial STIs. Chlamydia and gonorrhea urine checks are broadly available. Trichomoniasis urine checks also are available; however, they may be much less common. Bacterial culture was the gold preferred for diagnosing bacterial STIs, including chlamydia and gonorrhea.
Treatment
Pharmacotherapy: The patient is prescribed Ceftriaxone 250 mg IM and doxycycline 100 mg PO two times daily for 14 days (Savaris et al., 2020). Consider adding metronidazole 500 mg PO two times daily for 14 days.
Education
It is advisable to do the following to minimize chances of pelvic inflammatory disease; first is by using protection during sexual intercourse. Normalize getting tested for sexually transmitted infections and avoid douches (Savaris et al., 2020). After using the bathroom, the most important thing is to always wipe from front to back to prevent bacteria from entering your vagina. Abstinence is another method of ensuring that the patient takes all of her medications before engaging in sexual activity.
Follow Up
After seven days, the patient is advised to follow with her primary care provider.
Referral
Refer patient to a gynecologist if she is atypical, there is evidence of presumptive diagnosis, or hospitalization is required.
References
Cyr, S. S., Barbee, L., Workowski, K. A., Bachmann, L. H., Pham, C., Schlanger, K., … & Thorpe, P. (2020). Update to CDC’s treatment guidelines for gonococcal infection, 2020. Morbidity and Mortality Weekly Report, 69(50), 1911.
McQueen, B. E., Kiatthanapaiboon, A., Fulcher, M. L., Lam, M., Patton, K., Powell, E., … & Nagarajan, U. M. (2020). Human fallopian tube epithelial cell culture model to study host responses to Chlamydia trachomatis infection. Infection and immunity, 88(9), e00105-20.
Safrai, M., Rottenstreich, A., Shushan, A., Gilad, R., Benshushan, A., & Levin, G. (2020). Risk factors for recurrent pelvic inflammatory disease. European Journal of Obstetrics & Gynecology and Reproductive Biology, 244, 40-44.
Savaris, R. F., Fuhrich, D. G., Maissiat, J., Duarte, R. V., & Ross, J. (2020). Antibiotic therapy for pelvic inflammatory disease. Cochrane Database of Systematic Reviews, (8).
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