SOAP Note on Yeast Infection Example

SOAP Note on Yeast Infection. Record and post a complete History of Present Illness on a patient you have seen in clinical. Review the Medicare requirements for a billable note and Include at least 7 qualifiers, a brief past medical and surgical history, and your plan of care.

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SOAP Note on Yeast Infection

Verify Patient

          Name: XV

          DOB: 2/25/1992

Minor: N/A

Accompanied by: None

Gender Identifier Note: Female

CC: “I am experiencing vaginal pain accompanied by itching with a red and swollen vulva”.

HPI:  XV is a 30 y/o Black Hispanic female of Puerto Rican origin who presents to the clinic complaining of experiencing a vaginal itch with a burning sensation, particularly when urinating or having intercourse over the past three days. As per the patient, the vulva appears reddish and swollen. She further reports noticing a thick, white, odorless vaginal discharge with a cottage cheese appearance. She denied any blood in the urine and confirmed discomfort, pain, and a burning sensation when urinating or having intercourse. Using the PQRSTU pain assessment mnemonic, she qualifies her pain as follows;

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Provocative/ Palliative-– urination or having sexual intercourse and applying a cold compress around the vulva area respectively

Quality & Quantity – Itchy and burning all over the vaginal area.

Region and Radiation-Vulva and vagina and the pain begins in the vulva, extends to the vagina and increases in severity as it radiates towards the upper retrosternal area and the back.

Severity: On a scale of 0-10, XV rates her pain at 7/10 where O= no pain and 10= the worst pain imaginable.

Timing/ onset-Started six days ago but has worsened in the past three days. The pain starts when urinating or having intercourse and persists for 30 minutes or less.

Treatment- Applied plain Greek yoghurt to the vulva and around the vagina.

Understanding: The patient thinks her use of a birth control sponge over the last two weeks could be the cause of her current vaginal issues. She reports changing to contraceptive sponge use after her lover refused to use a condom. She admits to being sexually active with no history of STDs. She also complains of no medical or psychiatric issues and is not on medication.

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 Past Medical History

The patient has a history of recurrent UTI that was treated and successfully managed through Demeclocycline 300mg PO BID. This medication belongs to tetracycline antibiotics whose MOA involves binding to the 30S ribosomal subunit, thus inhibiting aminoacyl tRNA’s binding, effectively impairing protein synthesis by bacteria. Suffice it to say that this drug is bacteriostatic, meaning it impairs bacterial growth even without killing the bacteria directly.

Surgical history- The patient has never had a significant operation, but she had an appendectomy six weeks ago. This abdominal surgery, a medical history of using Demeclocycline and the recent use of birth control sponge may be the predisposing factors that encouraged the overgrowth of yeast in the patient’s vagina leading to yeast vaginitis or vaginal candidiasis (Schulz, 2017).

Diagnosis

B 37.3 Vaginal Candidiasis (confirmed)

B 96.8 Bacterial vaginosis (Refuted)

N 32.81 Overactive bladder (refuted)

Plan

I confirmed a diagnosis of B 37.3- Candidiasis of the vulva and vagina through a urine culture whose dipstick was negative for ketones and the presenting symptoms typical to this disease and ruling out bacterial vaginitis as Litmus Test PH were negative, thus ruling out BV (Paladime & Desai, 2018).

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The following treatment plan was recommended and undertaken.

• Use vaginal clotrimazole cream intravaginal once a day at bedtime for 3 to 7 days in a row (Medling et al., 2020). The cream should also be applied twice on the vulva and vagina external skin for the next seven days. Clotrimazole is an antifungal medication called imidazole with an MOA that works by blocking the growth of the fungi, causing infection. Some of the side effects include stomach pain, fever, chills, nausea, and vomiting. The patient is educated on how to relieve these symptoms. It is contraindicated in patients with allergies to clotrimazole and pregnant women.
• On non-pharmacological measures, the patient should take non-starchy vegetables, healthy proteins, and low gar fruits. The treatment plan also incorporated patient education on appropriate health promotion measures. For example, VD is a yeast infection, and therefore, the patient should complete her medication even after getting relieved. Completing the prescribed dose will help prevent the development of drug-resistant microorganisms. The patient is also advised to forgo sexual intercourse until after her health has improved, and the husband was also treated for yeast infection.

Referral to a STIs expert will be made if the symptoms worsen or no health improvement is noted after completing the dose.

Follow up: The patient was asked to come for a follow-up visit after two weeks.

References

Mendling, W., Atef El Shazly, M., & Zhang, L. (2020). Clotrimazole for vulvovaginal candidosis: More than 45 years of clinical experience. Pharmaceuticals, 13(10), 274.

Paladine, H. L., & Desai, U. A. (2018). Vaginitis: diagnosis and treatment. American family physician, 97(5), 321-329.

Schulz, L. (2017). Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients–Adult–Inpatient/Ambulatory Clinical Practice Guideline.

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