Focused Soap Note: Obstetric
Patient Name: MK Age: 36 years Race: Caucasian DOB: 5/23/1985
Chief Complaint (CC): Amenorrhea w/o pain
Reason for Visit: Visit for Annual Exam
History of Present Illness (HPI): The patient is a 36-year-old woman who reported to the clinic with complaints of amenorrhea without pain. The client reported she has a history of diabetes and she takes metformin to control it. She further reported she has a history of deficiency in vitamin D, dysmenorrhea, and menorrhagia with a regular menstrual cycle.
Onset; A week ago
Duration; Five to seven days
Alleviating & Aggravating factors; none
Past Medical & surgical History (PMH, PSH): She has a history of diabetes characterized by elevated HgbA1C 7.1 levels and takes metformin to control it. She also has a history of deficiency in vitamin D, moderate dysmenorrhea, and menorrhagia with a regular menstrual cycle. The last menstrual period was on 11/12/2021 and the last female annual exam was on 12/28/2021.
Family History: None
Family History: No history of cancer, anemia, hypertension, or heart disease.
Social History: MK is a happily married woman. She lives with her husband with four sons born on 1/2/2005 (3.3kg), 12/23/2008 (3kg), 2/23/2010 (3.5kg), and 3/6/2016 (3.4kg). All the sons were delivered vaginally. She does not smoke, use alcohol or abuse any illicit drugs or recreational drugs. She is unemployed and a stay home mum. She is a staunch Cristian.
Substance Abuse: She does not take any form of drug including caffeine, alcohol, smoking, or illicit drugs.
Infection Hx: None
Obstetrical History: G14P40104. She has a history of moderate dysmenorrhea and menorrhagia with a regular menstrual cycle. She denies dyspareunia or intermenstrual bleeding. However, she desires to have future fertility. Denies history of UTI but recent lab results reveal w/PCP (12/16/2021).
GYN Hx: History of one abnormal Pap, no colposcopy required
Sexual History: She is sexually active with one partner (her husband) and denies using any contraceptive.
Menarche: 12 years
Psychiatric Hx: Denies having any psychiatric conditions in the past.
Constitutional: Seems healthy and well nourished. Alert and oriented. Denies weight gain, mood swings, fever, and fatigue.
HEENT: No headache, dizziness, ear discharge, neck swelling, recent infections, tinnitus, head trauma, or sore throat.
Cardiovascular: Denies palpitation, chest pain, angina, or rapid heart rate.
Integumentary: Denies hair thinning, hair loss, rashes, or itching.
Gastrointestinal: C/o nausea. Denies vomiting, change in bowel habits abdominal pain, food intolerance, or diarrhea.
Genitourinary: Denies polyuria, nocturia, dysuria, urinary incontinence, or urgency.
Neurological: No head trauma or injury, headache cognitive decline or memory loss, difficulty concentrating, or sensorimotor function.
Musculoskeletal: Denies joint pain, no intermittent claudication, muscle pains, deformity, fractures, swelling, or stiffness.
Hematologic: Denies being anemic or having a blood, liver, or spleen condition.
Lymphatics: No enlarged lymph nodes at the neck, armpits, or groin.
Peripheral Vascular: No varicose veins, or tenderness on calves, legs, toes, or feet. Psychiatric: Denies history of psychiatric condition but experiences mood swings. Constitutional: Appearances to be healthy and well-nourished. Alert and focused. Weight gain, mood swings, fever, and fatigue are all denied.
HEENT: No dizziness, headache, ear discharge, neck swelling, recent infections, tinnitus, head trauma, or sore throat.
Cardiovascular: Refuses to acknowledge palpitation, chest pain, angina, or a rapid heart rate.
Hair thinning, hair loss, rashes, or itching are all denied.
C/o nausea, gastrointestinal. Denies any vomiting, bowel changes, abdominal pain, food intolerance, or diarrhea.
Denies polyuria, nocturia, dysuria, urinary incontinence, and urgency.
No head trauma or injury, cognitive decline or memory loss, difficulty concentrating, or sensorimotor function.
Musculoskeletal: There is no joint pain, intermittent claudication, muscle pain, deformity, fractures, swelling, or stiffness.
Hematologic: denies being anemic or having a problem with the blood, liver, or spleen.
No enlarged lymph nodes in the neck, armpits, or groin.
There are no varicose veins or tenderness in the calves, legs, toes, or feet. Psychiatric: Denies having a psychiatric condition but has mood swings.
Endocrine: Hx of diabetes and deficiency in vitamin D
Reproductive: Sexually active with her husband. Denies using protection.
Review of System (ROS):
Physical Exam: Vital Signs; Ht – 66, Weight – 163lbs, BMI – 26.3, Temp – 98.2, BP – 100/65, oxygen saturation – 98%, and RR-18.
Head/EENT: Head; Normocephalic and atraumatic with hair thinning. Identical pupils, no nasal deviation. Dry oral mucosa, pure oropharynx. The neck is supple with no nodules. Eyes have white sclera and pink conjunctiva.
Cardiovascular: Regular heart rate and rhythm.
Abdomen: Round, soft and non-tender on palpitation. Bowel sounds on all quadrants.
Breasts: Normal bilaterally symmetrical without masses, dimpling, discharge, or redness.
Extremities: Normal without clubbing, cyanosis, and edema. Palms and nails are normal. Ambulates without difficulty
Neurological: Normal No gross sensory or motor deficits.
Vagina: Normal. Vaginal vault unremarkable, with yellow-blood-tinged discharge. Irrigation
External Genitalia: Normal, no redness, swelling, or redness. Normal hair distribution.
Vulva/Labia Majora: Moist, full, symmetrical, soft tissue, and homogenous. No warts, lesions, redness, or sores were noted.
Clitoris: No redness or irritation was noted.
Cervix: Symmetric, midline, evenly distributed pink, and smooth. Closed and non-tender.
Pelvic: Normal and intact perineum.
Uterus: Normal, normal position, regular shape, and no prolapse.
Adnexa: Normal and deferred rectal.
Skin: No hair thinning, no patches, or skin discoloration.
Psych: Maintains eye contact, appears her age. Dressed for the weather. Alert and oriented.
• Leukorrhea – whitish or yellowish discharge
• Amenorrhea w/o pain, LMP 11/12/2021
• Urine pregnancy test (UPT) -negative today
• Rules out early intrauterine pregnancy (IUP)
• Desires elective terminations of pregnancy (ETOP)
• Recent labs w/PCP 12/16/2021
• History of elevated HgbA1C (7.1) – history of diabetes, taking metformin
• History of deficiency in vitamin D.
• H/o moderate dysmenorrhea, menorrhagia with regular menstrual cycle
• Urinalysis (81002) – pH -5; specific gravity (SG)-1 and Red blood cells (BLO) – positive.
Differential Diagnosis (DDx)
Leukorrhea or fluor albus is a vaginal discharge, which can be pathological or physiological. Physiological leukorrhea occurs during the menstrual process characterized by whitish to transparent colored and odorless discharge while pathological leukorrhea ranges from yellowish/greenish/greyish, smells fishy/foul smell vaginal discharge in large amounts causing itching, erythema, edema, burning sensation, dyspareunia and dysuria (Trilisnawati et al., 2018). Pathological leukorrhea is a non-infection disorder that causes vaginitis including foreign bodies, allergic vaginitis, and vulvar vestibulitis causing inflammation resulting in unpleasant odor and excess exudate in female patients. The clinical manifestation of leukorrhea in women includes vaginal discharge with itchiness. The discharge is a thin liquid and sometimes thick or sticky ranging from whitish, greyish-white, yellowish, greenish, reddish, dark colored, or rustic (Trilisnawati et al., 2018). Other associated symptoms include anorexia, constipation, and fatigue.
The diagnosis involves diagnostic procedures including physical examination, anamnesis, and supportive examination such as vaginal pH whiff/KOH test, and microbiologic examination. The Chief complaints associated with leukorrhea include increased volume in discharge, abnormal odor, spotting, itchiness, burning sensation, and dyspareunia. Other factors to consider include lower abdominal pain, frequency of intercourse, and hx of STD or partner sex. Homogeneous adherent white discharge, vaginal pH above 4.5, amine odor after discharge, and Nugent score above 4 supporting examinations confirm the diagnosis of leukorrhea. The patient meets the criteria for leukorrhea upon presenting yellowish discharge, blood-tinged discharge (RB; +ve), vaginal pH above 4.5 (5), amine odor, and pelvic pain.
N76.0: Bacterial Vaginitis (BV)
BV is caused by an overgrowth of normal vaginal flora and is normally characterized by increased fish-like odor vaginal discharge typically whitish or gray. Although BV is not considered a sexually transmitted infection (STI), the bacteria can spread among sexually active individuals due to alteration of natural bacterial flora balance within the vagina leading to the development of BV (Kairys & Garg, 2022). Ideally, a reduced number of normal hydrogen peroxide produce Lactobacilli with an overgrowth of anaerobic bacteria causing BV. Majority of women with BV present malodorous vaginal discharge especially after sexual intercourse, although the condition can be asymptomatic. Additional symptoms include dysuria, dyspareunia, and vaginal pruritus (Kairys & Garg, 2022). As clinicians, it is crucial to elicit pertinent history on risk factors such as a history of BV, recent antibiotic use, vaginal douching, use of an intrauterine device, and the number of sexual partners. A proper exam involves pelvic exam is needed to rule out presenting conditions such as trichomoniasis, cervicitis, herpes simplex virus, candidiasis, chlamydia, and gonorrhea. Assessing pelvic exam, fever, and history of STI helps in ruling out other serious conditions or differential diagnoses. A clue cell is a reliable diagnostic sign for BV by examining vaginal fluid under a microscope. The Amsel criteria help in the diagnosis of BV characterized by a thin white, a yellow, homogenous discharge vaginal fluid pH greater than 4.5, the release of a fishy odor, no vulva inflammation or discomfort or itch, and clue cells on microscopy (Kairys & Garg, 2022; Sim et al., 2020). However, the patient does not meet the criteria for diagnosis since the vaginal disorder is odorless.
The patient could be diagnosed with dysmenorrhea. Dysmenorrhea is defined as painful monthly bleeding it can either be primary or secondary. Primary dysmenorrhea is characterized by lower abdominal pain during the menstrual cycle while secondary dysmenorrhea is associated with other pathological factors inside or outside the uterus: Women during reproductive age experience emotional, psychological, and functional health impressions and associated risk factors such as nulliparity, high BMI, early menarche age, family history of dysmenorrhea and longer menstrual flow (Nagy & Khan, 2021). Clinical manifestations include nausea, fatigue, vomiting, headache, and diarrhea. As such, a comprehensive history is needed to establish a diagnosis including a history of pain, location, duration, and character. Typical common findings indicative of secondary dysmenorrhea include older age above 25 years, vaginal discharge whitish gray in color due to inflammatory diseases, pelvic masses, and other associated factors infertility, dysuria, dyspareunia, dyschezia, nodularity, adnexal masses, and tenderness due to non-gynecological etiology or endometriosis (Nagy & Khan, 2021). Therefore, the evaluation process involves pregnancy tests, ultrasound, and risk of STIs, clinical examination to rule out malignancy cervical cytology samples, Doppler ultrasonography, and laparoscopy. Although the patient is overweight (BMI -26.3) and has a foul-smelling whitish discharge, nausea, older age, pelvic pain, and a history of dysmenorrhea, she does not meet the criteria for dysmenorrhea since she has no pelvic masses intact adnexal masses, and no tenderness.
The management of the patient’s condition involves a prescription of azithromycin 1 gram single dose orally or doxycycline 100 mg twice a day orally for seven days and patient education on genital area hygiene (Trilisnawati et al., 2018). Patient education will also use of condoms, delayed sexual intercourse for a week after completing treatment, safe sex, minimizing exposure to the sun which can cause photosensitivity, avoiding tight synthetic clothing, and douching. The patient should be educated on the clinical manifestation of normal physiologic or pathological occurrence and manifestation related to vaginal and how to differentiate them along with the use of point of care tools such as narrow-spectrum pH paper in assessing vaginal infection (Sim et al., 2020). The plan involved several procedures such as irrigation medicate vagina (57150), and ultrasounds such as transvaginal (76830), pelvic (76856), and duplex scan abdominal and pelvic (93976). Other laboratory and diagnostic tests included urinalysis (81002), venipuncture (36415), pregnancy test (81025), Pap collection (Q0091), and breast exam (G0101).
Performing a urine culture on vaginal swabs helps in ruling out a diagnosis of BV or detect detection of BV-associated microorganisms and other complications such as Gardnerella vaginalis (G. vaginalis), Prevotella bivia (P. bivia), and Lactobacillus crispatus (L. crispatus) (Naicker et al., 2021). The patient was referred to Dr. Irina Mikheyeva, a gynecologist for ETOP consultation as a standard treatment for diagnoses of retained foreign bodies, cervical ectopy, suspected tumors in the genital tract, or upper infection. The referral will help in the diagnosis of recurrent vulvovaginal infection and failure of treatment strategies (Sim et al., 2020). The prognosis in the management of leukorrhea involves examination and treatment processes applying a syndromic approach especially if associated with hormonal factors. The patient is overweight (BMI – 26.3) and has a history of diabetes hence the need for psych counseling, osteoporosis screening, nutritional counseling, physical activity counseling, Pap pelvic exam, and BMI follow-up plan. The patient is a new client under CPT code 99385 aged between 18-39, advised to take a flu vaccine under CPT code 99203 and visit the clinic after two weeks. Overweight patients are at higher risk of developing osteoporosis which affects the myoskeletal system characterized by low bone density and reduced muscle mass and strength hence the need for screening. As such, nutrition counseling including intake of protein and vitamin D intake along with resistance and endurance exercises prevents osteoporosis and management of diabetes (Papadopoulou et al., 2021).
Kairys N, & Garg M. [2022) Bacterial Vaginosis. StatPearls [Internet]. Treasure Island (FL). StatPearls Publishing; Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK459216/
Nagy, H., & Khan, M. A. (2021). Dysmenorrhea. In StatPearls [Internet]. StatPearls Publishing. Retrieved from https://www.statpearls.com/ArticleLibrary/viewarticle/20798
Naicker, D., Ramsuran, V., Naicker, M., Dessai, F., Giandhari, J., Tinarwo, P., & Abbai, N. (2021). Strong correlation between urine and vaginal swab samples for bacterial vaginosis. Southern African Journal of Infectious Diseases, 36(1). https://doi.org/10.4102%2Fsajid.v36i1.199
Papadopoulou, S. K., Papadimitriou, K., Voulgaridou, G., Georgaki, E., Tsotidou, E., Zantidou, O., & Papandreou, D. (2021). Exercise and Nutrition Impact on Osteoporosis and Sarcopenia—The Incidence of Osteosarcopenia: A Narrative Review. Nutrients, 13(12), 4499. https://doi.org/10.11622%2Fsmedj.2020088
Sim, M., Logan, S., & Goh, L. H. (2020). Vaginal discharge: evaluation and management in primary care. Singapore medical journal, 61(6), 297.
Sim, M., Logan, S., & Goh, L. H. (2020). Vaginal discharge: evaluation and management in primary care. Singapore medical journal, 61(6), 297. https://doi.org/10.11622%2Fsmedj.2020088
Trilisnawati, D., Izazi Hari Purwoko, Mutia Devi, Suroso Adi Nugroho, Fitriani, & Theresia L. Toruan. (2021). Etiology, Diagnosis, and Treatment of Leukorrhea. Bioscientia Medicina : Journal of Biomedicine and Translational Research, 5(6), 571-590. https://doi.org/10.32539/bsm.v5i6.323