NUR 656 Module 8 SOAP Note Example

SOAP Note: Vaginal Discharge in a 29-Year-Old Diagnosed as Bacterial Vaginosis by Amsel Criteria

[Student Name]

Southern New Hampshire University

NUR 656: Primary Care of Women

Module Eight SOAP Note

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

SOAP Note: Vaginal Discharge in a 29-Year-Old Diagnosed as Bacterial Vaginosis by Amsel Criteria

Few complaints bring women to primary care more often than vaginal discharge, and the three usual causes, bacterial vaginosis, candidiasis and trichomoniasis, are often treated empirically on the basis of symptoms. Symptom-based diagnosis is frequently wrong, leading to repeated visits, unnecessary antifungal use and missed sexually transmitted infections. A few minutes of office testing can make the diagnosis reliable. Danielle is a 29-year-old seen for discharge and odor. This SOAP note documents her evaluation and treatment. It argues that a structured differential, objective criteria, guideline-based treatment and counseling about recurrence provide better care than treating symptoms alone.

Subjective

Chief concern: "I have a smell I can't get rid of."

History of present illness: Danielle reports seven days of increased thin, grayish discharge with a fishy odor that is stronger after intercourse and after her period, which ended nine days ago. She has no itching, burning, pain with intercourse, pelvic pain, fever or abnormal bleeding. She douched twice last week to control the odor. She had similar symptoms a year ago treated with an antifungal cream from the pharmacy, which did not help. Her relationship with her male partner has lasted two years, and she relies on a copper IUD; condoms are not used. She has no new partners. Last STI testing was a year ago and negative. Medications: none. Allergies: none.

Objective

Vital signs normal. External genitalia without erythema or lesions. On speculum view, a thin, even, grayish film clings to the vaginal walls; the cervix looks healthy, does not bleed on contact and shows no pus-like discharge. Moving the cervix causes no pain, and the adnexa are not tender. Office testing: vaginal pH 5.0; a fishy amine odor when potassium hydroxide was added to the discharge sample; saline microscopy showing clue cells making up about 30% of epithelial cells, no motile trichomonads and few white blood cells; potassium hydroxide microscopy without yeast or pseudohyphae.

Assessment

1. Bacterial vaginosis. Amsel et al. (1983) described clinical criteria for what was then called nonspecific vaginitis: a thin, homogeneous discharge; vaginal pH above 4.5; a positive amine or whiff test; and clue cells on microscopy. The presence of three of the four supports the diagnosis. Danielle meets all four. In research and laboratory settings, the Nugent score, a standardized method of interpreting a Gram stain of vaginal fluid by counting bacterial morphotypes, is considered the reference standard for diagnosis (Nugent et al., 1991); Amsel criteria remain practical and accurate for office use.

Differential diagnoses: vulvovaginal candidiasis, unlikely given absence of itching, normal pH expected in candidiasis and no yeast on microscopy, which also explains why her earlier antifungal cream failed; trichomoniasis, unlikely with no motile organisms, though microscopy misses many cases; and cervicitis from chlamydia or gonorrhea, unlikely with a normal cervix but not excluded without testing. Douching is a known risk factor for bacterial vaginosis.

Plan

The 2021 CDC sexually transmitted infections treatment guidelines recommend metronidazole 500 mg orally twice daily for seven days, metronidazole gel 0.75% intravaginally once daily for five days or clindamycin cream 2% intravaginally at bedtime for seven days for bacterial vaginosis, and note that refraining from alcohol during metronidazole treatment is no longer considered necessary (Workowski et al., 2021). Danielle chose the oral route, so she will take 500 mg of metronidazole every twelve hours for a week. Because microscopy misses many cases of trichomoniasis, a vaginal nucleic acid amplification test for trichomonas, chlamydia and gonorrhea was sent, with HIV and syphilis testing offered and accepted. Her copper IUD does not need removal.

Partner management: the guidelines do not recommend routine treatment of male partners, since trials have not shown that it reduces recurrence. She was advised to stop douching, which disrupts the protective lactobacilli, and told that condom use may reduce recurrence. A test of cure is not needed if symptoms resolve.

Why It Matters Beyond Symptoms

Bacterial vaginosis is more than a nuisance. It reflects a shift in the vaginal ecosystem from protective lactobacilli, which keep the pH low, to a mixture of anaerobic bacteria. Women with this imbalance are more likely to pick up other sexually transmitted infections, HIV among them, with pelvic inflammatory disease after gynecologic procedures and, in pregnancy, with preterm birth. These associations are one reason to confirm the diagnosis rather than guess, to test for other infections at the same visit and to treat symptomatic women. For Danielle, who has a copper IUD, the associations do not require removing the device, but they do support treating the infection promptly and returning if she develops pelvic pain or fever.

The visit also explained why her earlier treatment failed. Many women assume that any discharge or odor is a yeast infection and use over-the-counter antifungal products. Surveys of women who self-diagnose have found that many do not actually have candidiasis. Using antifungals for bacterial vaginosis delays effective treatment and can leave women frustrated and repeatedly symptomatic. Danielle was shown her own test results, including the elevated pH and clue cells, so that she could see why this infection is different and why it needs a different medicine.

Counseling About Recurrence

Danielle was told that bacterial vaginosis often returns. Bradshaw et al. (2006) followed women after treatment with oral metronidazole and found that more than half had a recurrence within twelve months, with recurrence associated with factors such as having a regular sexual partner and a history of the condition. Knowing this helps patients recognize a recurrence as common rather than as a treatment failure or a sign of infidelity. She was asked to return if symptoms recur, in which case a longer or suppressive regimen could be considered, and to avoid treating herself with antifungal products, since her symptoms have not been caused by yeast.

Conclusion

Danielle's odor and discharge had been misattributed to yeast. A structured differential and a few office tests confirmed bacterial vaginosis by all four Amsel criteria. Guideline-based metronidazole, STI testing, advice to stop douching and honest counseling about recurrence address both the current episode and the likelihood of future ones.

References

Amsel, R., Totten, P. A., Spiegel, C. A., Chen, K. C., Eschenbach, D., & Holmes, K. K. (1983). Nonspecific vaginitis: Diagnostic criteria and microbial and epidemiologic associations. The American Journal of Medicine, 74(1), 14-22. https://doi.org/10.1016/0002-9343(83)91112-9

Bradshaw, C. S., Morton, A. N., Hocking, J., Garland, S. M., Morris, M. B., Moss, L. M., Horvath, L. B., Kuzevska, I., & Fairley, C. K. (2006). High recurrence rates of bacterial vaginosis over the course of 12 months after oral metronidazole therapy and factors associated with recurrence. The Journal of Infectious Diseases, 193(11), 1478-1486. https://doi.org/10.1086/503780

Nugent, R. P., Krohn, M. A., & Hillier, S. L. (1991). Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. Journal of Clinical Microbiology, 29(2), 297-301. https://doi.org/10.1128/jcm.29.2.297-301.1991

Workowski, K. A., Bachmann, L. H., Chan, P. A., Johnston, C. M., Muzny, C. A., Park, I., Reno, H., Zenilman, J. M., & Bolan, G. A. (2021). Sexually transmitted infections treatment guidelines, 2021. MMWR Recommendations and Reports, 70(4), 1-187. https://doi.org/10.15585/mmwr.rr7004a1