Using the format Create a SOAP note for a female with a diagnosis of bartolinitis, include also gynecological history. Use scholarly references no older than 5 years.
SOAP Note for a Female Patient with a Diagnosis of Bartholinitis
Subjective:
Chief Complaint (CC): “Pain and swelling in the vaginal area for the past three days.”
History of Present Illness (HPI): A 28-year-old female presents with complaints of pain and swelling in the vaginal area, particularly on the left side. The symptoms began three days ago, starting as a mild discomfort which has progressively worsened. The patient describes the pain as sharp and throbbing, with a pain score of 7/10. She reports difficulty sitting and walking due to the discomfort. There is no history of fever, chills, or vaginal discharge. The patient denies any recent trauma or injury to the area.
Gynecological History:
Menarche at age 12
Regular menstrual cycles, 28 days, lasting 5 days with moderate flow
Last menstrual period (LMP): 10 days ago
Gravida 1, Para 1, Abortions 0
History of normal vaginal delivery 3 years ago
No history of sexually transmitted infections (STIs)
Last Pap smear: 1 year ago, results normal
Contraceptive use: Oral contraceptive pills for the past 5 years
Sexual History: Sexually active with one partner, reports using condoms inconsistently
Past Medical History (PMH): No significant medical history
Past Surgical History (PSH): None
Family History (FH): No significant family history
Social History (SH): Non-smoker, occasional alcohol use, no recreational drug use
Allergies: No known drug allergies
Medications: Oral contraceptive pills (ethinyl estradiol and norethindrone)
Objective:
Vital Signs:
Temperature: 98.6°F
Heart Rate: 78 bpm
Blood Pressure: 120/80 mmHg
Respiratory Rate: 16 breaths per minute
Physical Examination:
General: Well-appearing female in mild distress due to pain
Abdomen: Soft, non-tender, no masses
Pelvic Examination:
External genitalia: Erythema and swelling noted on the left labia majora
Bartholin gland: Palpable, tender mass approximately 2 cm in diameter on the left side
No signs of abscess or purulent discharge
Speculum examination: Vaginal walls and cervix appear normal
Bimanual examination: Uterus and adnexa non-tender, no masses
Assessment:
Primary Diagnosis:
Bartholinitis (inflammation of the Bartholin gland)
Differential Diagnoses:
Bartholin gland abscess
Cystocele
Vulvar abscess
Inguinal lymphadenopathy
Plan:
Diagnostics:
None indicated at this time based on clinical presentation
Medications:
Prescribe broad-spectrum antibiotics: Amoxicillin-clavulanate 875 mg/125 mg orally twice daily for 7 days
Pain management: Ibuprofen 600 mg orally every 6 hours as needed for pain
Procedures:
Warm sitz baths: Advise the patient to take warm sitz baths 3-4 times a day to help with pain and swelling
Patient Education:
Educate the patient on the importance of completing the full course of antibiotics
Instruct the patient on signs of abscess formation (increased pain, fever, purulent discharge) and to seek immediate medical attention if symptoms worsen
Discuss the importance of consistent use of barrier protection methods to reduce the risk of infections
Follow-up:
Schedule follow-up appointment in 1 week to reassess symptoms and response to treatment
References:
Sobel, J. D. (2020). Vulvovaginitis and other common vaginal infections. In Ferri’s Clinical Advisor 2020 (pp. 1377-1379). Elsevier.
Foster, D. C. (2019). Bartholin gland duct cyst and gland abscess: Clinical manifestations and diagnosis. In UpToDate. Retrieved from Diagnosis of Bartolinitis and Gynecological History appeared first on Nursing Depo.
