Diagnosis of Bartolinitis and Gynecological History

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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.

diagnosis of bartolinitis and gynecological history

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:

  1. Diagnostics:
    • None indicated at this time based on clinical presentation
  2. 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
  3. Procedures:
    • Warm sitz baths: Advise the patient to take warm sitz baths 3-4 times a day to help with pain and swelling
  4. 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
  5. Follow-up:
    • Schedule follow-up appointment in 1 week to reassess symptoms and response to treatment

References:

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