Nursing
To prepare:
Use the Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment.
Select a patient that you examined during the last three weeks. With this patient in mind, address the following in your Focused Note Template.
Assignment
Subjective: What details did the patient provide regarding her personal and medical history?
Objective: What observations did you make during the physical assessment?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. 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, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation
ANSWER
Episodic/Focused SOAP Note Template
Patient Information:
35 years, female
S.
CC (chief complaint): The patient comes into the clinic complaining of vaginal itchiness that begun 5 days ago.
HPI: The patient is a 35 year old female alert, well-nurtured and developed and appears to be in no acute suffering. The patient has a vaginal itchiness that begun 5 days ago with a thick white vaginal cottage cheese like discharge with intense itching. Patient says that she is very tender and red around the outside of her vagina.
Location: Vagina
Onset: 5 days ago
Character: Vagina itching
Associated signs and symptoms: thick white vaginal cottage cheese like discharge
Timing: N/A
Exacerbating/relieving factors: N/A
Severity: 7/10 pain scale
Current Medications: None
Allergies: No states allergies or known drug allergies.
PMHx: LMP less than 30 Days ago. Birth Control Method was oral. Last Pap test was 6 years ago which shown Cytology negative & human papillomavirus with history of abnormal Pap -Last Mammogram N/A.
Soc & Substance Hx: She denies smoking, alcohol, and any other form of drug abuse.
Fam Hx: No family history stated.
Surgical Hx: Denies of any prior surgeries.
Mental Hx: No mental history stated.
Violence Hx: No violence history stated.
Reproductive Hx: LMP less than 30 Days ago
ROS:
GENERAL: Well-nourished, developed, cooperative, alert and appears to be in no acute suffering.
HEENT
Head: Normal hair pattern
Eyes: No blurred vision, visual loss, yellow sclerae or double vision.
Ears: No infections or drainage. Ears are normal bilaterally.
Nose: Denies any nosal congestion or sneezing
Throat: No sneezing, hearing loss, runny nose, congestion, or sore throat.
Neck: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.
SKIN: No itching, no lacerations, bruising, rashes, or open wounds.
CARDIOVASCULAR: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits.
RESPIRATORY: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds.
GASTROINTESTINAL: No vomiting, constipation, diarrhea or nausea, or change in bowel habits.
GENITOURINARY: Denies hesitancy, incontinence, frequency, and dysuria, or any other abnormalities. LMP less than 30 Days ago
NEUROLOGICAL: No seizures, falls, and migraines, paralysis, ataxia no change in bladder control or bowel.
MUSCULOSKELETAL: No osteoporosis, no back pain, no joint pain, stiffness, or muscle ache.
HEMATOLOGIC: No sickle cell disease, no complications from transfusion or chemotherapy, no bleeding, or any hematologic diseases.
LYMPHATICS: No enlarged lymph nodes, no swollen glands, or any lymphatic diseases.
PSYCHIATRIC: No history of anxiety or depression.
ENDOCRINOLOGIC: No adrenal insufficiency and polydipsia. The patient reports feeling cold all the time.
ALLERGIES: No history of any known allergies or drug allergies.
REPRODUCTIVE: Redness recognized to labia minora and majora. Pelvic exam discloses large amount of thick white cottage cheese like vaginal discharge, no bleeding or foul odor noticed. No lesions or abnormalities note to cervix. No cervical motion tenderness with bimanual exam. No masses or tenderness noted to bilateral ovaries. Uterus is normal size but is slightly tiled to the left
O.
Physical exam:
Vital signs: BP 125/ 76 Pr 88 RR 20 temp 98.1
General: Well-developed, well-nourished, alert and cooperative, and appears to be in no acute distress.
HEENT: Reports of vaginal itchiness and a thick white vaginal cottage cheese like discharge with intense itching.
Diagnostic results: Urine dipstick for U/A- Negative, Vaginal Wet Mount- negative for bacteria. Moderate amount of yeast noted on wet.
A.
Differential Diagnoses
Yeast Infections: Vaginal yeast infection causes discharge and intense itchiness and irritation of the vagina. Yeast infection ranges from mild to moderate symptoms that include irritation and itching in the vagina, swelling and redness of the vulva (Byrne and Reboli, 2017). Yeast infection leads to a white, thick, odor free vaginal discharge with cottage cheese appearance (Hay, 2018).
Bacterial Vaginosis: Bacterial vaginosis is a kind of vaginal inflammation which is a result of overgrowth bacteria naturally occurring in the vagina. Therefore, this occurs as a result of change in the normal balance of vaginal bacteria. Bacterial vaginosis may have vaginal discharge, itching and burning with a white or grey color and have an unpleasant and strong smell (Hay, 2014).
STIs: STIs consist of infections that an individual can contract after having sexual contact with another person that has STIs. STIs such as genital warts and genital herpes can cause vulvar and vaginal discomfort or itching (Mashburn, 2012). For instance, genital herpes makes urination painful, pain, irritation and itching around the inner thighs and genital area.
The treatment pan will come out as a natural consequence of taking certain steps. Relevant information about the case will be gathered from the patient history and examined to highlight a list of problems. The diagnosis will be established to determine the need for special consultations and tests. After the establishment of various diagnosis, different treatment options will be considered and their likely priorities. For this case vaginal treatment will include antibiotics to eliminate yeast infections and sexually transmitted infections. Metronidazole 500mg pills twice a day for seven days will be prescribed to prevent possible problems of bacterial vaginosis. After the treatment, follow up care through regular medical checkups will be conducted to prevent recurrence of vaginal itching and infections.
Health promotion and disease prevention focuses on ensuring people are healthy. Physical examination is essential in assessing how the patient is doing as well as checking on the symptoms to effectively assess the areas of health that require attention. The health assessment is essential in determining if a patient requires diagnostic testing or additional medical care. Patient factors such as gender, age and cognitive ability influences health promotion and disease prevention. These patient factors are essential in determining the treatment options. If a patient says that they have a certain condition or feeling for the past few days, they cannot know about the condition until they are told. Clinicians should focus on subjective and objective data obtained through interviews, observation, diagnostic and laboratory testing and physical examination.
References
Byrne, D. D., & Reboli, A. C. (2017). Rare yeast infections: risk factors, clinical manifestations, treatment, and special considerations. Current Clinical Microbiology Reports, 4(4), 218-231.
Hay, P. (2014). Bacterial vaginosis. Medicine, 42(7), 359-363.
Hay, P. (2018). Vaginal discharge. Medicine, 46(6), 319-324.
Mashburn, J. (2012). Vaginal infections update. Journal of midwifery & women’s health, 57(6), 629-634.
