SOAP NOTE
Title: L.V Date: 29th August, 2020 Time: 0900 Hrs
Age: 16 years Intercourse: Feminine
SUBJECTIVE
CC: The affected person experiences of getting vaginal bleeding and UCG, belly ache and pelvic ache with some uncommon vaginal discharge 2 weeks after having unprotected intercourse.
HPI: The affected person is G1P0 and is at the moment four weeks + 5 days pregnant by the final menstrual interval (LMP) of 15/eight/2020. She had residence being pregnant check 4 days in the past. She denies any nausea and is reporting a gentle breast tenderness. She has vaginal bleeding and a few uncommon discharge following the unprotected sexual activity of two weeks in the past. She experiences of huge quantity of the yellowish to white vaginal discharge with no odor and he or she is at the moment sporting a pad. The discharge began one to 2 weeks in the past. She by no means skilled any ache throughout her final sexual activity. There was no itching nor burning sensation. She denies of any earlier discharge (Elwell et al., 2016).
Drugs: She is underneath no medicine at current
PMH: she denies the historical past of main sickness, accidents, blood transfusion, or hospitalization. She is able to performing her ADLs efficiently.
Allergic reactions: NKDA
Medicine Intolerances: No medicine intolerance
Persistent Sicknesses/Main traumas: denies any historical past of power illness or main traumas. She has not been recognized with hypertension, diabetes, bronchial asthma, lung illness, Tuberculosis, or most cancers.
Hospitalizations/Surgical procedures: denies any historical past of hospitalization or any surgical process
Household Historical past: The mom is a stay and has historical past of hypertension. Her maternal grandfather is having a historical past of adult-onset of diabetes mellitus.
Social Historical past: she resides along with her dad and mom in a local people and he or she has no job. She has made an try to use for the WIC and the Medicaid advantages final week after studying about her being pregnant. She is at the moment single with no man to specify as her boyfriend. She denies of any abusive setting (Witkin, Minis, Athanasiou, Leizer , & Linhares , 2017).
ROS
Common: she denies fever, no discount of weight, fatigue, or diminished urge for food. She experiences of getting common weight loss plan reminiscent of fruit and veggies.
Cardiovascular: Denies palpitations or dyspnea on exertion
Pores and skin: No bruises or rashes famous. No discoloration Respiratory: no shortness of breath, cough, or congestion
Eyes: No use of corrective lenses, no blur, no change within the imaginative and prescient
Gastrointestinal: denies nausea, vomiting, and diarrhea.
Ears: No ache of the ear or loss within the listening to. Denies of ear discharge
Genitourinary/Gynecological: Denies frequency or urgency in urination or dysuria. There may be vaginal discharge. No historical past of pap or mammo
Nostril/Mouth/Throat: Absence of sinus points, absence of discharges and nostril bleeds, no dental sickness, no throatiness, no throat ache, and no dysphagia
Musculoskeletal: belly ache and pelvic ache
Breast: delicate breast tenderness
Neurological: No seizure, weak spot, blackout out spells, or paralysis.
Heme/Lymph/Endo: the affected person is HIV detrimental, no bruises, no historical past of blood transfusion, no evening sweats, and chilly or warmth intolerance. She denies having swollen glands or improve in thirst.
Psychiatric: experiences of no earlier sickness or despair. She denies of any sleeping
OBJECTIVE
Weight 54 BMI 20.three Temp 97.5 BP 110/70
Top 163 cm Pulse 60 Resp 18
Common Look: she is alert, cooperating, well-nourished feminine with no misery, and is unaccompanied to the power.
Pores and skin: Brown, heat, clear and intact. No lesions or rashes.
HEENT: Head-normocephalic, atraumatic with no lesions. Even distribution of hair. Eyes: PERRLA and intact EOMs. There isn’t any conjunctival or scleral injection; Ears-bilateral TMS, patent canals, and the seen landmarks; Nostril-pinkish nasal mucosa, regular 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. Tooth is in good restore.
Cardiovascular: there may be common charge and coronary heart rhythm, no gallop or murmur, no tachycardia, pulses are 2+ ×four ext.
Respiratory: There may be symmetrical chest wall, common and simple respiration, and lungs with clear to bilateral auscultation.
Gastrointestinal: non-palpable liver and spleen, no CVA tenderness, smooth and non-tender stomach, non-palpable fundus, rounded stomach.
Breast: a gentle breast tenderness with no plenty or discharge. There isn’t any dimple, wrinkle, and discoloration of the pores and skin.
Genitourinary: The exterior genitalia WNL with no lesions. The speculum examination with out clean, darkish pink, and nulliparous cervix. Heavy deposits of thicker mild yellowish discharge with no odor. There are not any adnexal plenty that’s palpable.
Musculoskeletal: Full ROM is seen in all of the four extremities as affected person is ready to transfer concerning the examination room.
Neurological: Affected person A & O × three. The speech is having clear with good tone. She is having erected posture, steady with unchanged gait
Psychiatric: the affected person is alert and oriented, keep eye contact, responding to the questions in applicable method, and smooth speech.
Lab Exams
Urine is optimistic for HCG, UA WNL with detrimental glucose, protein, and ketones
There may be proof of leukocytes underneath moist preparation, absence of trichomonas or clue cells, no hyphae.
Particular Exams
KOH detrimental underneath whiff check
Prognosis
Differential Diagnoses
False optimistic being pregnant check: the optimistic HCG is anticipated for affected person on the HCG weight loss plan, molar, or ectopic being pregnant
Ectopic Being pregnant: affected person denies ache and subsequently, it is very important take into account it in differential till there may be positivity for IUP on sono
Sexually transmitted an infection i.e. Chlamydia or gonorrhea: that is doable as a result of larger quantity of thicker and yellow discharge. There are not any clue cells, hyphae or the trichomonas noticed underneath moist preparation, and the unpredictable utilization of condoms and that is revealed by the optimistic being pregnant.
Prognosis
Chlamydia: as a result of bigger quantity of discharge and the vaginal bleeding.
Plan/Therapeutics
o Plan:
▪ Full blood depend (CBC) to assist in the evaluation for anemia; Urine CX as a result of prospects of the asymptomatic bacteriuria throughout being pregnant; Syphilis, HIV, and the Hepatitis B screening to assist in the detection of the STIs that may be a danger to the fetal well being; Gyn Probe for the G/C chlamydia to assist in the detection of the sexually transmitted an infection that may intrude with the well-being of the affected person; ultra-sound to assist in the affirmation of the IUP and the EDD; Rubella and the VZC titer to forestall the publicity of the fetus to the chance of the detrimental titer of the mom; and the blood sort and the rhesus components to assist in decide the doable Rh incompatibility in case the mom is Rh-.
▪ Medicine: Azithromycin 19 PO ×1; ceftriaxone 250 mg IM ×1, and the retest on the subsequent go to.
▪ Training: The affected person is educated to keep away from sexual exercise till seven days; affected person is suggested to make a name or return to the power in case the signs fail to scale back; affected person taught to keep away from douches or different vaginal irritants; affected person suggested to plan for the prenatal care by visiting. The affected person is suggested to name the supplier when she experiences the signs associated to the bleeding, fever, contractions, critical or abrupt swell, and ROM. Affected person is suggested to have a nutritious diet i.e. improve within the fruit and veggies in addition to lean protein. The affected person is suggested to not take smooth or unpasteurized cheeses.
▪ Non-medication remedies: The affected person can take garlic because it has antibacterial and the anti-inflammatory results. It additionally has the antifungal properties that struggle the expansion of yeast which makes it useful in the course of the antibiotic therapy for chlamydia (Wilson, 2019).
Analysis of affected person encounter: The affected person is alert and well-oriented, however she has a priority about her vaginal bleeding and different signs that’s offered within the facility. She just isn’t effectively knowledgeable about her situation, subsequently, requires each medical and schooling consideration within the administration of her situation.
References
Elwell, C., Mirrashidi, Okay., & Engel, J. (2016). Chlamydia cell biology and pathogenesis. Nature Opinions Microbiology, 14(6), 385-400.
Wilson, R. D. (2019, March 26). Why House Treatments for Chlamydia Are a Dangerous Concept. healthline: https://www.healthline.com/well being/sexually-transmitted-diseases/home-remedies-for-chlamydia
Witkin, S., Minis, E., Athanasiou, A., Leizer , J., & Linhares , I. M. (2017). Chlamydia trachomatis: the persistent pathogen. Medical and Vaccine Immunology, 24(10).
