Bacterial Vaginosis Zahavah is a 16 years Gender: Female Race: non-Hispanic White Diagnosis: bacterial vaginosis Subjective Data: HJ is a 16-year-old Hispanic female patient who presented to the office with her mother with a two week history of severe irritation and soreness of her vulva. The patient reported of having a two-week history of burning sensation on passing urine without increased urinary frequency. In addition, the patient complained of having a thick, creamy-white vaginal discharge. She had normal and regular menstrual periods. She agreed to having multiple sexual partners for the last one year since breaking up with her high school boyfriend. She denied taking medications in the management of the issue of concern. Objective Data: Vital signs; BP 110/76, HR 78, RR 26, temperature 98, and an oxygen saturation of 99 percent on room air. In general, HJ was a healthy lad who was well oriented to place, time, and person, without obvious distress. HEENT without issues of concern. On respiratory assessment, the patient had a clear and normal lung sounds bilaterally without crackles and wheezes. Cardiovascular assessment showing normal heart sound without murmurs and gallops. Normal bowel sounds on all quadrants on gastrointestinal examination. Patient denied to have a physical examination on the perineal area. Assessment: History of presenting illness indicating a possible bacterial vaginosis. Positive Whiff test indicating bacterial vaginosis. Plan of care: Clindamycin 300 mg orally twice daily for 7 days was prescribed to help in the management of the issues. Patient educated on the need to avoid multiple sexual partners to avoid reoccurrence of the issue as well as possible sexually transmitted diseases. Answer below QUESTION · Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies. · Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues. · Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why? · Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. · Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation? Note: Your Focused Note Assignment must be signed by Day 7 of Week 3. PRAC 6541: .

1. Bacterial Vaginosis
Zahavah is a 16 years Gender: Female Race: non-Hispanic
White Diagnosis: bacterial vaginosis Subjective Data: HJ is a
16-year-old Hispanic female patient who presented to the office
with her mother with a two week history of severe irritation
and soreness of her vulva. The patient reported of having a two-
week history of burning sensation on passing urine without
increased urinary frequency. In addition, the patient complained
of having a thick, creamy-white vaginal discharge. She had
normal and regular menstrual periods. She agreed to having
multiple sexual partners for the last one year since breaking up
with her high school boyfriend. She denied taking medications
in the management of the issue of concern. Objective Data:
Vital signs; BP 110/76, HR 78, RR 26, temperature 98, and an
oxygen saturation of 99 percent on room air. In general, HJ was
a healthy lad who was well oriented to place, time, and person,
without obvious distress. HEENT without issues of concern. On
respiratory assessment, the patient had a clear and normal lung
sounds bilaterally without crackles and wheezes. Cardiovascular
assessment showing normal heart sound without murmurs and
gallops. Normal bowel sounds on all quadrants on
gastrointestinal examination. Patient denied to have a physical
examination on the perineal area. Assessment: History of
presenting illness indicating a possible bacterial vaginosis.
Positive Whiff test indicating bacterial vaginosis. Plan of care:
Clindamycin 300 mg orally twice daily for 7 days was
prescribed to help in the management of the issues. Patient
educated on the need to avoid multiple sexual partners to avoid
reoccurrence of the issue as well as possible sexually
transmitted diseases.
Answer below QUESTION
· Subjective: What details did the patient or parent provide
regarding the personal and medical history? Include any

2. discrepancies between the details provided by the child and
details provided by the parent as well as possible reasons for
these discrepancies.
· Objective: What observations did you make during the
physical assessment? Include pertinent positive and negative
physical exam findings. Describe whether the patient presented
with any growth and development or psychosocial issues.
· Assessment: What were your differential diagnoses? Provide a
minimum of three possible diagnoses. List them from highest
priority to lowest priority and include their ICD-10 code for the
diagnosis. What was your primary diagnosis and why?
· Plan: What was your plan for diagnostics and primary
diagnosis? What was your plan for treatment and management?
Include pharmacologic and non-pharmacologic treatments,
alternative therapies, and follow-up parameters as well as a
rationale for this treatment and management plan.
· Reflection notes: What was your “aha” moment? What would
you do differently in a similar patient evaluation?
Note: Your Focused Note Assignment must be signed by Day 7
of Week 3.
PRAC 6541:
Primary Care of Adolescents and Children
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a
brief statement identifying why the patient is here in the
patient’s own words, for instance, “headache,”
not “bad headache for 3 days.”
HPI: This is the symptom analysis section of your note.

3. Thorough documentation in this section is essential for patient
care, coding, and billing analysis. Paint a picture of what is
wrong with the patient. Use LOCATES Mnemonic to complete
your HPI. You need to start
every HPI with age, race, and gender (e.g., 34-year-old
African American male). You must include the seven attributes
of each principal symptom in paragraph form, not a list. If the
CC was “headache,” the LOCATES for the HPI might look like
the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia,
phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen
makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time
used, and reason for use. Also include over-the-counter (OTC)
or homeopathic products.
Allergies:
Include medication, food, and environmental allergies
separately. Provide a description of what the allergy is (e.g.,
angioedema, anaphylaxis). This will help determine a true
reaction versus intolerance.
PMHx: Include immunization status (note date of
last tetanus for all adults), past major illnesses, and
surgeries. Depending on the CC, more info is sometimes
needed.
Soc & Substance Hx: Include occupation and major

4. hobbies, family status, tobacco and alcohol use (previous and
current use), and any other pertinent data. Always add some
health promotion questions here, such as whether they use seat
belts all the time or whether they have working smoke detectors
in the house, the condition of the living environment, text/cell
phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition,
contagious illnesses, or chronic illnesses. The reason for death
of any deceased first-degree relatives should be included.
Include parents, grandparents, siblings, and children. Include
grandchildren if pertinent.
Surgical Hx:
Prior surgical procedures.
Mental Hx:
Diagnosis and treatment. Current concerns: (Anxiety
and/or depression). History of self-harm practices and/or
suicidal or homicidal ideation.
Violence Hx:
Concern or issues about safety (personal, home,
community, sexual—current and historical).
Reproductive Hx: Menstrual history (date of last menstrual
period [LMP]), pregnant (yes or no), nursing/lactating (yes or
no), contraceptive use (method used), types of intercourse (oral,
anal, vaginal, other), and any sexual concerns.
ROS: This covers all body systems that may help you include or
rule out a differential diagnosis. You should list each system as
follows:
General:Head:
EENT: and so forth. You should list these in bullet
format and document the systems in order from head to toe.

5. Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing,
congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest
discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or
diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. LMP:
MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis,
ataxia, numbness, or tingling in the extremities. No change in
bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain,
or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat
intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No
reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head to toe, include
what you see, hear, and feel when conducting your
physical exam. You only need to examine the systems that are
pertinent to the CC, HPI, and history.
Do not use “WNL” or “normal.” You must describe
what you see. Always document in head-to-toe format (i.e.,
General: Head: EENT:).

6. Diagnostic results: Include any labs, x-rays, or other diagnostics
that are needed to develop the differential diagnoses (support
with evidenced and guidelines).
A.
Differential Diagnoses (list a minimum of 3 differential
diagnoses). Your primary or presumptive diagnosis should be at
the top of the list. For each diagnosis, provide supportive
documentation with evidence-based guidelines.
P.
Includes documentation of diagnostic studies that will be
obtained, referrals to other health care providers, therapeutic
interventions, education, disposition of the patient, and any
planned follow-up visits. Each diagnosis or condition
documented in the assessment should be addressed in the plan.
The details of the plan should follow an orderly manner.
Also included in this section is the reflection. The
student should reflect on this case and discuss whether or not
they agree with their preceptor’s treatment of the patient and
why or why not. What did they learn from this case? What
would they do differently?
Also include in your reflection a discussion related to health
promotion and disease prevention, taking into consideration
patient factors (e.g., age, ethnic group), PMH, and other risk
factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based, peer-
reviewed journal articles or evidenced-based guidelines that
relate to this case to support your diagnostics and differentials
diagnoses. Be sure to use correct APA 7th edition formatting.
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