SOAP Note on Pelvic Inflammatory Disease
United State University
SOAP Note on Pelvic Inflammatory Disease
Client’s Initials: G.H, Age: 23, Gender: Female, Race: Caucasian American, Date of Birth: January 01, 1999.
CC: “I have vagina discharge, pelvic pain, and fever.”
HPI:Â 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:Â No major chronic diseases but has had mild flu, treated by home remedies such as ginger.
Surgery: No medical surgery.
Family History:Â 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:Â 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:Â She has not encountered headaches, has not lost consciousness and has no numbness.
Eyes:Â 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 hasÂ no abnormal tears in her eyes.
Ears:Â 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:Â 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:Â 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:Â she feels a sore throat and has trouble swallowing especially solid meals.
Neck:Â she does not have any stiffness, meningeal symptoms, or suppleness; she also does not have anyÂ bruits.
Skin, Hair, and Nails:Â According to the patient,Â she has not had any rashes, also sheÂ noÂ changes in skin tone. She has no abnormalities in hair colorÂ or nails.
Cardiovascular:Â She has no vibrations, she has noÂ chest pain, noÂ breathlessness, noÂ congestion, she has noÂ heart sounds, noÂ anemia, orthopnea.
Integumentary and Breast:Â She has no inflammation, lesion, or rash. She has no lumpiness.
Gastrointestinal: Has regular bowel habits. She hasÂ 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 hasÂ no hematochezia
Genitourinary:Â She denies urine urgency, has no dysuria, and normal urine frequency.
Musculoskeletal:Â There are no joint pains, she hasÂ no inflammations, no bruises, no muscle cramps, no disk failure, noÂ backaches, no arthritis, and the body partsÂ move normally.
Neurological:Â SheÂ does not have headaches, noÂ head traumas, noÂ seizures, noÂ infections of the brain; she has not had a loss of memory. She does experienceÂ fainting, epilepsy, tremor, orÂ paralysis.
Psychiatric:Â There have been no suicide attempts, she is not depressed or facingÂ anxiousness, she has no memory alteration.
Allergies:Â There are no documented drug allergiesÂ or food sensitivities, and sheÂ not allergic to pollen orÂ animal fur.
Temperature: 37.4â„ƒ Height:176 cm Weight:55 BP:124/72, RR: 19 SpO2: 99% Pain: 70% in the pelvic BMI: 17.8
Constitutional:Â She is attentive, friendly, and healthy-looking.
Head:Â Her head shape is Noncephalic. She has thick hair that is evenly scattered across the scalp.
Eyes:Â 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:Â On examination, she has no swellings and no hearing deficiency.
Nose:Â She does not have a discharge from the nose, no swellings, no sinus deviation, no splenic tenderness.
Mouth:Â She does not have gum disease. No lip wounds, no tongue swellings or wounds. The dentistry formula is in the normal range. She hasÂ no erythema or discharge in the oropharynx. Mucosal membranesÂ are moist. Also,Â 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:Â 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:Â Breath sounds normal, and there are no wheezes, crackles, or coughs. No dyspnea
Cardiovascular:Â There are no chestÂ 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:Â There is bilateral abdominal and pelvic pain noted.
Musculoskeletal:Â The strength and tone of the motors are normal. Extremities are normal; there is no cyanosis.
Genitourinary/Gynecological:Â 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.
Pelvic inflammatory diseaseÂ N73. 9-Â 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 A74.9Â 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 infectionÂ 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.
Pelvic Exam:Â 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.
Pharmacotherapy:Â The patient is prescribed Ceftriaxone 250 mg IM and doxycycline 100 mg PO two times daily for 14 days (Savaris et al., 2020).Â Consider adding metronidazole 500 mg PO two times daily for 14 days.
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.
After seven days, the patient is advised to follow with her primary care provider.
Refer patient to a gynecologist if she is atypical, there is evidence of presumptive diagnosis, or hospitalization is required.
Get Professional Assignment Help Cheaply
Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?
Whichever your reason is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.
Why Choose Our Academic Writing Service?
- Plagiarism free papers
- Timely delivery
- Any deadline
- Skilled, Experienced Native English Writers
- Subject-relevant academic writer
- Adherence to paper instructions
- Ability to tackle bulk assignments
- Reasonable prices
- 24/7 Customer Support
- Get superb grades consistently
Online Academic Help With Different Subjects
Students barely have time to read. We got you! Have your literature essay or book review written without having the hassle of reading the book. You can get your literature paper custom-written for you by our literature specialists.
Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.
While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.
Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.
In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.
Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.
We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!
We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.
Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.
What discipline/subjects do you deal in?
We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.
Are your writers competent enough to handle my paper?
Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.
What if I don’t like the paper?
There is a very low likelihood that you won’t like the paper.
- When assigning your order, we match the paper’s discipline with the writer’s field/specialization. Since all our writers are graduates, we match the paper’s subject with the field the writer studied. For instance, if it’s a nursing paper, only a nursing graduate and writer will handle it. Furthermore, all our writers have academic writing experience and top-notch research skills.
- We have a quality assurance that reviews the paper before it gets to you. As such, we ensure that you get a paper that meets the required standard and will most definitely make the grade.
In the event that you don’t like your paper:
- The writer will revise the paper up to your pleasing. You have unlimited revisions. You simply need to highlight what specifically you don’t like about the paper, and the writer will make the amendments. The paper will be revised until you are satisfied. Revisions are free of charge
- We will have a different writer write the paper from scratch.
- Last resort, if the above does not work, we will refund your money.
Will the professor find out I didn’t write the paper myself?
Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.
What if the paper is plagiarized?
We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.
When will I get my paper?
You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.
Will anyone find out that I used your services?
We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.
How our Assignment Help Service Works
1. Place an order
You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.
2. Pay for the order
Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.
3. Track the progress
You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.
4. Download the paper
The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.
PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET A PERFECT SCORE!!!