Soap Note Gastritis

“I am having vaginal itching and pain in my lower abdomen.”

Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.

Protonix 40mg PO Daily for GERD

MTV OTC PO Daily

Advil 200mg OTC PO PRN for pain

Allergies: 

NKA & NKDA

Medication Intolerances:

Denies

Chronic Illnesses/Major traumas

GERD

Hospitalizations/Surgeries

 Denies

Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.

Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.

Denies weight change, fatigue, fever, night sweats

Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water

Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions

Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water

Denies corrective lenses, blurring, visual changes of any kind

Abdominal pain (see HPI) and Hx of GERD. Denies N/V/D, constipation, appetite changes

Denies Ear pain, hearing loss, ringing in ears

Reports burning with urination, but denies frequency or urgency. Contraceptive and STD prevention includes condoms with every coital event. Current stable sexual relationship with one man. Denies known historic or recent STD exposure. Last PAP was 7/2016 and normal. Regular monthly menstrual cycle lasting 3-4 days.

Denies sinus problems, dysphagia, nose bleeds or discharge

Denies back pain, joint swelling, stiffness or pain

Denies SBE

Denies syncope, seizures, paralysis, weakness

Denies bruising, night sweats, swollen glands

Denies depression, anxiety, sleeping difficulties

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.

Skin is normal color for ethnicity, warm, dry, clean and intact. No rashes or lesions noted.

Head is norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in good repair.

S1, S2 with regular rate and rhythm. No extra heart sounds.

Symmetric chest walls. Respirations regular and easy; lungs clear to auscultation bilaterally.

Abdomen flat; BS active in all 4 quadrants. Abdomen soft, suprapubic tender. No hepatosplenomegaly.

Suprapubic tenderness noted. Skin color normal for ethnicity. Irritation noted at labia majora, minora, and perineum. No ulcerated lesions noted. Lymph nodes not palpable. Vagina pink and moist without lesions. Discharge minimal, thick, dark red, no odor. Cervix pink without lesions. No CMT. Uterus normal size, shape, and consistency.

Full ROM seen in all 4 extremities as patient moved about the exam room.

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Alert and oriented. Dressed in clean clothes. Maintains eye contact. Answers questions appropriately.

Urinalysis – blood noted (pt. on menstrual period), but results negative for infection

Urine culture testing unavailable

Wet prep – inconclusive

STD testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B & C

· 1-Bacterial Vaginosis (N76.0)

· 2- Malignant neoplasm of female genital organ, unspecified. (C57.9)

· 3-Gonococcal infection, unspecified. (A54.9)

Diagnosis

· Urinary tract infection, site not specified. (N39.0) Candidiasis of vulva and vagina. (B37.3) secondary to presenting symptoms (Colgan & Williams, 2011) & (Hainer & Gibson, 2011).

· Medication –

· Terconazole cream 1 vaginal application QHS for 7 days for Vulvovaginal Candidiasis;

· Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days for UTI (Woo & Wynne, 2012)

· Education –

· Medications prescribed.

· UTI and Candidiasis symptoms, causes, risks, treatment, prevention. Reasons to seek emergent care, including N/V, fever, or back pain.

· STD risks and preventions.

· Ulcer prevention, including taking Protonix as prescribed, not exceeding the recommended dose limit of NSAIDs, and not taking NSAIDs on an empty stomach.

· Follow-up –

· Pt will be contacted with results of STD studies.

· Return to clinic when finished the period for perform pap-smear or if symptoms do not resolve with prescribed TX.