Case Assignment: Diagnostic plan

Case Assignment: Diagnostic plan
Case Assignment: Diagnostic plan

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PLAN:

Diagnostic plan: Oligonucleotide probes test will be ordered and send out to outside diagnostic lab company. Wet mount test, KOH/whiff test, and litmus test for pH were all ordered and tested. Results: positive.

Treatment and Management:

Bacterial vaginosis resolved spontaneously for most women, but the patient has been having the symptoms for one week. I will use an antibiotic therapy.

Antibiotics Therapy:

Metronidazole (Flagyl), 500 mg orally twice daily for seven days .

Alternative Therapy

I will recommend probiotics, such as Lactobacillus acidophilus, which will help eliminate high levels of bad bacteria and replace them with good bacteria. The rationale is that acidophilus is a known good bacteria. Also, I will recommend apple cider vinegar; the rationale is that bacterial vaginosis is caused be change in vaginal pH. The apple cider vinegar is natural acidic compound and will help regulate the patient body pH and naturally restore pH balance (Machado, Castro, Palmeira-de-Oliveira, Martinez-de-Oliveira, & Cerca, 2015). In addition, I will recommend hydrogen peroxide because hydrogen peroxide is natural disinfecting agent, and patient will be directed to insert tampon soaked with 3% hydrogen peroxide purchased at drugstore, the goal is to eliminate bad bacteria in the patient body (Machado et al., 2015).

Nonpharmacological Treatment:

Yogurt will be recommended to the patient, and patient advised to eat two cups of plain yogurt daily. Rationale is to restore normal pH balance in the vagina inhibiting the growth of bad bacteria. Moreover, tea tree oil will be recommended to the patient, and patient will be instructed to add few drops of tea tree oil in warm water, stir the water and use the water to rinse vaginal daily for three to 4 weeks (Machado et al., 2015). The rationale is to kill the bacteria that cause bacterial vaginosis as well as eliminate the foul fishy odor associated with bacterial vaginosis because tea tree oil has both natural antibacterial and antifungal compounds. Furthermore, patient will instructed to eat raw or cooked garlic daily because the garlic natural antibiotic properties. The rationale is to keep the eliminate bad bacterial (Machado et al., 2015).

Health Promotion:

Patient will be educated to wipe from front to back instead of back to front to void contaminating the vagina with bacterial from the rectum. Also, patient will be educated to keep her vulva clean and dry. In addition, patient will be educated to refrain from using agents that are irritating in her vagina, such as strong soaps, feminine hygiene sprays, or douching. Furthermore, patient will be educated to abstain from tight jeans, panty hose with no cotton crotch, or clothing that trap moisture. Have only single sex partner and use condom (Public Health, 2015).

Reflection Note and Follow-Up

What I will do differently on a similar patient evaluation is that I will check the patient hemoglobin A1C to rule out diabetic origin of the condition . I would send the patient home to try the recommended home remedies for few days and come back for antibiotic treatment since bacterial vaginosis can be resolved without treatment to prevent antibiotic resistance. Patient will be schedule to follow-up in 14 days to repeat the diagnostic test to make sure that the infection is cleared, and if the infection is not cleared, I will repeat antibiotic treatment. I agree with my preceptor diagnosis based on the available positive test results and clinical guidelines .

References

Centers for Disease Control and Prevention. (2016). Genital/vulvovaginal candidiasis.

Retrieved from http://www.cdc.gov/fungal/diseases/candidiasis/genital/index.html

Centers for Disease Control and Prevention. (2016). Trichomoniasis. Retrieved from

http://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm

Machado, M., Castro, J., Palmeira-de-Oliveira, A., Martinez-de-Oliveira, J., & Cerca, N.

(2015). Bacterial vaginosis biofilms: Challenges to current therapies and emerging solution. Front Microbiol, 6, 1528-1542. doi: 10.3389/fmicb.2015.01528

Public Health. Bacterial vaginosis: Women’s health guide. Retrieved from

http://www.publichealth.va.gov/infectiondontpassiton/womens-health-

guide/bacterial-vaginosis.asp

Women’s Health. (2015). Bacteria vaginosis. Retrieved from

http://womenshealth.gov/publications/our-publications/fact-sheet/bacterial-

vaginosis.html

SOAP note rubric

Subjective (15 points)
Points Possible
Points Earned
· CC
1
1
· Pertinent positives (OLDCARTS)
5
5
· Pertinent negatives & positives (from ROS)
5
4
· Pertinent PMH, SH, and FH
3
3
· Medications and drug/food allergies are included
1
1
Objective (15 points)
· VS including FHT if indicated
3
3
· Thyroid, Heart, and Lungs
1
1
· Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included.
-5
1
· Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted.
-5
5
· Diagnostic test results (ex; BHCG, CBC, Rubella, RPR, pap, GC, CT, 1 HR GTT, GC/CT, urine dip, wet prep, Blood group & RH Status)
2
2
Assessment (10 points for each priority diagnosis to equal 30)
30
30
Plan (15 points)
· Medications discontinued (“d/c lisinopril 10 mg daily”)
1
NA/1
· Medications started (“start Ferrous Sulfate 325 mg daily”)
2
2
· Alternative therapies if appropriate (1 point)
1
NA/1
· Diagnostic tests ordered with timeframe
6
6
· Referrals or consultations if appropriate
2
2
· Follow-up interval
3
3
Reflection notes (25 points)
· What did you learn from this experience? Any ah-ha’s? (5 points)
5
0
· What would you do differently?
5
5
· What additional data would you have gathered?
5
5
· What additional elements of the exam would you have done?
50Do you agree with your preceptor based on the evidence?
55
Total points
100
85
Overall great work on your first SOAP note, please see comments.

�Great CC, clear concise in patient’s own words.

�Great use of OLDCARTS

�Great history

�Any fever, chills, fatigue?

�She

�Unnecessary

�Unnecessary

�Unnecessary in this case

�Unnecessary in this case

�Unnecessary in this case

�Unnecessary in this case

�Great

�Great choice, first line treatment for BV

�This may be beneficial in recurrent cases however besides fam hx, patient does not have any other risk factors, young, normal BMI.

�In The reflections you are to list What did you learn from this experience? Not addressed.

What would you do differently? You addressed this.

What additional data would you have gathered? You addressed this.

What additional elements of the exam would you have done? Not addressed

Do you agree with your preceptor? You addressed this.

See SOAP note template, even if you don’t have anything to add, just state that with the question.