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DISCUSSION POST # 1 Video. Reply to Regine

Note: you can talk about Bacterial Vaginosis

SOAP note
Bacterial Vaginosis

Hello students: My presentation is regarding patient with Bacterial Vaginosis

Pt with date of birth 1129 1997 age 25 Hispanic

female presents to the clinic AC

unaccompanied Chief complaint unpleasant

vaginal odor and widish discharge that

worsens after sex with husband history

of present illness she is a 25-year-old

female patient presents to Clinic with

concern about having a 3 we vagina odor

and whest discharge she states that she

has not had this dis before and the

onset of odor and discharge was sudden

she states that when she has intercourse

with her husband the problem worsens she

also states that the problem improves

but does not go away when abstaining

from sexual activity she has not had any

type of treatment except vaginal

douching but thought that it would just

go away with time when asked about

douching she states that she does not

often she does it often at the end of

her cycle she also states that the odor

is very unpleasant and fish like

she notes that she is in a monogamous

relationship with her husband of 10

years she also claims there are no cause

for (STD) sexual transmitted disesase concerns past medical history uh

chicken pox at the age of seven

childhood sinus infections last known at

age five surgical has not been

hospitalized uh wisdom teeth removed at

age 14 denies any allergies medications

on birth control Earth or Ortho tricycle

28 days does not take vitamins or

supplements vaccinations are up to date

coVID 19

booster I received um early this year uh

flu shot uh done two weeks ago social

history denies tobacco usage drinks

occasionally is a social Drinker States

two drinks per month usually red wine

denies street drug usage she lives with

her her husband no children they have

many relatives nearby including her

mother father and sisters she is active

in her local Catholic parish she is

sexually active with her husband and

states that the relationship is loving

and monogamous she states that her

husband is the only sexual partner she

has had and vice versa she does not want

children at the moment and she works as

a DA she’s very comfortable with her job

she stats she has little to know

stress her husband is a general

contractor who owns his own business

family history there’s no pertinent

family

history review of systems generally the

patient reports no fever chills cough uh

she does not report lethargy or loss of

Interest eyes patient reports no

blurring visual changes or pain ears

nose throat mouth patient reports no

hearing loss ear pain or ear

discharge um no nose bleeds no sinus

congestion no sneezing denies any tooth

pain or changes last dental exam and

cleaning was 2 weeks ago denies any

mouth pain sores or dry mouth

cardiovascular denies chest pain

palpitation skin discolorations

pulmonary denies dpia wheezing cyanosis

finger clubbing or puic pain nuro denies

headaches dizziness numbness pins and

needle Sensations endocrine denies

intolerance to cold and

heat the normal 28 day cycle of

menstruation and last menstruation was 2

weeks

prior lymph denies lymphatic enlargement

swelling denies allergies to medications

and environment GI denies diarrhea

constipation loss of appetite or blood

in the stool gu denies urinary changes

discolorations pain or changes in

urgency she has um mild periods last

menstrual period completed 6 days prior

to exam

she is positive for whitish milky

vaginal discharge vaginal odor mild

discharge

dyspareunia and vaginal partis

psychiatric no suicidal

ideation objective vital signs are

within normal limits temperatures 97

Fahrenheit taken orally pulse is 71

respiration 16 blood pressure 114 over

70 oxygen saturation 99% pain is 0 out

of 10 weight is 128 height is 54 BMI is

22 normal weight no Labs or Radiology

studies to review generally the patient

appears to be healthy welldeveloped

um well maintained um and no distress

Cooperative responsible to questions and

alert no signs of abuse skin is color

and natural with consistent ethnicity n

visible lesions lumps growth or

wounds h&t eyes are clear without exate

red light reflex is present bilaterally

neck is non- tender no palpable cervical

lymph nodes thyroid is midline neuro

alert oriented times 4 answers all

questions

appropriately um cranial nerves 1

through 12 are intact cardio S1 and S2

or without clicks or murmers cap refill

is less than 2 seconds abdomen is soft

and non- tender to light and deep

palpation B sounds are present in all

four quadrants gu and pelvic exam

genitalia normally develop without

lesions there is non- distended blad

curea is no visible lesions masses color

is appropriate for skin tone pelvic exam

the examination was performed with the

speculum non-tender cervix free of

lesions or masses she’s positive for

increased cervical redness positive for

whsh yellow thin discharge positive for

foul fish like odor and positive for

bloody

discharge uh vaginal swabbing was

performed and sent for

cytology it is a positive for wet Mount

pH 5.7 plus clue cells assessment

differentials um could be um herpes

simplex virus cervicitis and bacterial

vaginosis um final diagnosis is

bacterial vaginosis because it’s

evidenced by the history of douching and

the presence of symptoms on the am

criteria

um plan for Diagnostics is to be

confirmed by the wet Mount evaluation of

the vaginal swab the sample was

evaluated for pH 5.7 and clue cells were

present clinically the patient is

matching the criteria on the Anse

criteria such as uh thin yellow white

discharge fishy odor increased vaginal

pH clue cell presence and gram

staining would further um provide

information regarding organism oral

growth we would also run some (STD)sexual transmitted disease

testing such as HIV herpes Chia Gara

treatment overall would be used uh

flagle antibiotic po two times daily for

7 Days uh five at 500

milligrams uh education

includes um instructing the patient to

always wipe from front to back use a

mild soap when cleaning the patient also

needs to be instructed to not consume Al

alcohol during the course of antibiotic

therapy and up to 72 hours after

antibiotic completion the patient needs

to be educated to complete the

antibiotic regimen even if symptoms

resolve patient should return to the

clinic if um symptoms don’t

subside and after the antibiotic course

and if she feels any other um symptoms

patient is instructed to return to the

clinic for an annual exam next year.

DISCUSSION POST
#2 Video Reply to Angelo

SOAP Note ADHD Attention hyperactive Disorder

Note: you can talk about ADHD in children.

Hi students: I am going to be

presenting um my soap note for this week

um my patients initials are RJ and he is

a 9-year-old Hispanic

male um he was accompanied by his father

during this

visit and

um so I found this a

complex diagnosis as to um the reasoning

is because he is a psych patient um

father comes in for a complaint of his

son’s concentration level at home as

well as at

school

um um sorry about

that uh let me try to let me see you

sorry I’m reviewing my HPI real quick um

so the father’s the patient’s father

complains that the child is exhibiting

self-centered Tendencies and he doesn’t

appear to be thinking about others

needs um he has also started throwing

Tantrums um he’s finding difficulty

paying attention in school according to

his

teachers um he’s not raising his hand

when in

class uh past medical history there is

none preventative care he is up to date

on everything he has met all his

milestones for a

9-year-old um no hospitalizations no

allergies to medications food or

seasonal

allergies current medications is just a

multivitamin family medical history um

when performing this mother and father

there are

none um it seems like just regular

family history such as hypertension

diabetes in the patient’s Grand

father um social history he is in the

fifth

grade he’s attending school every day of

the week when he’s not at school he is

with his

grandmother um waiting for his parents

to get out of work review of systems

everything was normal besides psych

psychiatric um he reports of inability

to focus complaints of hyperactivity and

impulsiveness reports being unable to

wait his turn and lacking attention at

home and in school as well as reports of

anxiety vital signs are all within

normal limits he

is doing great on the height and weight

percentile for his age physical exam

everything seemed normal besides being a

little bit anxious not making any eye

contact UM with

communication as well as showing

impulsivity and is extremely active in

the exam

room some differentials that I created

for this patient were Oppositional Defiant Disorder

but

when asking the father during the HPI he

didn’t have any aggressive or angry

actions including being loud or

belligerent um so I was able to roll

that diagnosis out I also included as a

differential by

bipolar um but again with the re review

of systems and HPI the patient was not

manic or depressive or he didn’t show

any of those symptoms I should

say um didn’t have I mean yes he had

mood swings but to a certain

extent um it can also show suicidal

thoughts and sleeplessness which the

patient did not show so I was able to

roll that one out so for his diagnosis I

came up with

(ADHD) Attention Deficit Hyperactive Disorder um by this diagnosis I used the

screening tool from

DSM-5 DTR where the parents and the

teacher were involved in the

questionnaire um Diagnostics I don’t

think there are any treatment plan would

be starting the patient on Ritalin the

lowest dose 2.5 MGR PID

one with breakfast and one with lunch as

well as a possible Behavioral Health

referral um to help further manage this

patient the good thing about Ritalin is

that it can be tight titrated up if needed

um some education for this patient would

be starting the medication on a weekend

so the parents can monitor for any

adverse reactions as well as informing

the teacher as well as the school nurse

that this patient is now starting this

medication.