Soap Note 1

SOAP Note 1

Encounter date: March 22nd, 2021

Patient Initials: K.P

Gender: M/F/Transgender: Female

Age: 25

Race: Black

Ethnicity: African- American

Reason for Seeking Health Care

“My vulva and vagina irritate and itches."

History of Present Illness

HPI: An 11-year-old African American girl presented at the office complaining of vaginal itchiness. She reports the onset began three days ago. She states she has itchiness in the vagina and the discomfort is a constant feeling. K.P states the discomfort comes along with a thick, smelly vaginal discharge, vaginal itchiness, redness, sore and uvula swelling. She says there is no aggravating factors as well as no reliving factors. She denies any use of medication to treat this issue. She rates the pain a 7 on a scale from 0 to 10.

Allergies

K.P denies no known allergies. K.P does not have any allergies to herbal supplements, environmental factors, drugs, latex, food, drugs or latex.

Current perception of Health

K.P present discernment of health is good. She is able to explain how she feels without any trouble.

Past Medical History

· Major/Chronic Illnesses: K.P denies any major/chronic illnesses.

· Trauma/Injury: K.P denies any trauma/injuries.

· Hospitalizations: K.P denies any history of hospitalizations.

· Pregnancy: K.P denies any history of pregnancy. She reported being sexually active and noted using pills for family planning.

· Menstruation: K.P reports first menstruation at the age of thirteen years, which has been regular with moderate flow.

Past Surgical History

K.P denies pas surgical history

Medication

K.P denies any use of prescribed medications.

K.P admits taking OTC One A Day Women's Prenatal 1 tablet per day.

Family History

Father is currently alive however he suffers from diabetes.

Mother is currently alive and is healthy.

Maternal grandmother is alive however she has hypertension.

Maternal grandfather is alive and healthy.

Paternal grandmother has hearing loss.

Paternal grandfather has hearing loss.

Younger sister is healthy.

Older brother is healthy. K.P denies family history of tuberculosis, epilepsy, mental illness, kidney disease and anemia.

Social History

Living conditions: K.P lives with her fiancé in a two-bedroom apartment.

Family: K.P has a dog and lives with her fiancé. Her mom and dad and siblings live 10 minutes from her. Her grandparents live 30 minutes from her.

Marital status: She is engaged to her boyfriend who she’s been with for 6 years.

Occupation: K.P is a registered nurse. Her fiancé is a doctor.

Tobacco: K.P denies any use of tobacco.

ETOH/drugs: K.P denies any use of recreational drugs. However, she admits drinking alcohol twice a week.

Sexual state and use of contraceptives: K.P is currently sexually active. She denies the use of contraceptives. She is trying to conceive. ADL: K.P denies any difficulties with her ADL’s.

Health Maintenance

The latest pap smear was done today in clinic, pending results. The next Pap smear is set on 3/2022.

The latest eye exam was done on 1/2021, normal, and the next vision test will be done on 1/2022.

The latest labs were done on 1/2021, normal, next one scheduled for 1/2022.

Patient does not need colonoscopy screening done at this moment.

Patient does not need mammogram done at this moment.

Exposures

K.P denies any harmful exposures.

Immunizations History

K.P reports all her vaccinations are up to date and is pending the COVID19 vaccine when available.

Review of Systems:

General: Denies abnormal weight gain. Denies fever/chills. Denies night sweats. Denies allergies. Denies anemia. Denies malaise/fatigue. Denies weakness.

HEENT: Denies headaches. Denies head injuries. Denies eye redness. Denies eye pain. Denies eye discharge. Denies blurry or double vision. Denies decreased hearing. Denies ear pain. Denies nasal congestion. Denies nasal drainage. Denies sinus pain. Denies decrease sense of smell. Denies bleeding gum. Denies dry mouth. Denies hoarse voice. Denies thrush. Denies nonhealing sores.

Neck: Denies swelling. Denies stiffness. Denies mass. Denies swollen glands.

Lungs: Denies frequent cough. Denies shortness of breath. Denies wheezing. Denies pain with breathing. Denies phlegm.

Cardiovascular: Denies chest tightness. Denies palpitations. Denies trouble breathing at night. Denies fatigue easily with exercise. Denies ankle swelling.

Breast: Denies any mass. Denies discharge from nipples. Denis lumps.

GI: Denies bloating. Denies incontinence. Denies abdominal discomfort. Denies nausea. Denies diarrhea. Denies emesis.

Female genital: Admits irritation. Admits itchiness in the vulva and vagina. Admits experiencing her first menarche at the age of 13 years. Admits vaginal discharge (thick, white, smelly discharge with a cottage cheese appearance)

GU: Denies discomfort and burning. Denies loss of bladder control. Denies. Urgency to urinate. Denies vaginal discharge. Denies being sexually active. Denies STDs.

Neuro: Denies loss of consciousness. Denies drowsiness. Denies vertigo. Denies tremors. Denies syncope. Denies dyskinesia. Denies numbness. Denies seizures. Denies headaches.

Musculoskeletal: Denies joint and muscle ache. Denies swollen joints. Denies deformity. Denies chronic back pain.

Activity & Exercise: Admits undertaking regular exercises of 60 minutes of cycling 3 days a week and taking low caloric diets.

Psychosocial: Denies mood changes. Denies psychological stress. Denies anxiety. Denies suicidal thoughts. Denies delusions. Denies hallucinations. Denies irritability.

Derm: Denies rash. Denies cyanosis. Denies bleeding. Denies bruising. Denies itching. Denies rashes. Denies warts. Denies acne.

Nutrition: Admits taking adequate water. Admits intake in vegetables and fruits. Admits taking limited animal protein.

Sleep/Rest: Denies apnea. Denies difficulty with sleep.

LMP: Admits LMP was on February 22nd, 2021.

STI Hx: Denies history of STDs

Physical Exam

Vital Signs: BP: 124/81 TPR: 98.2 F. HR: 80 bpm RR: 19 bpm Wt. 110 lbs Ht. 5’ 0” BMI (percentile) 21.5 kg/m2

General: K.P is a 25-year-old African American female who presents to the clinic with complaints of vaginal irritation and itchiness with abnormal discharge. K.P is well-groomed and healthy with no signs of severe distress.

Head: Normocephalic and atraumatic. No lesions presented on scalp. No scars. Normal hair distribution. Hair is black and evenly distributed. Eyes: Vision 20/20. PERRLA. Sclera is red, the conjunctiva is pink. Intact movement of extra-ocular muscles. Some discharge presented, ptosis, or enophthalmos. Pupils 3mm. Ears: No discharge, hearing conduction normal, AC> BC. No signs of ear infection or discharge. No signs of lesions or sores. No redness. Weber midline. Nose: No discharge, mucosa pink, no polyps. Midline septum. Nasal patency intact. No sinus tenderness noted. Mouth: No oral thrush, no cheilitis, no ulcers, no tongue papillae atrophy. Patient’s uvula is midline and has gag reflex. Tongue midline. Dentition good. Pharynx is without exudates.

Derm: Skin is warm, dry and intact. Skin is normal with standard hair distribution and temperature. No redness. No edema noted. No bruises noted. No blisters, ulcers or flaky skin noted. Ulcerations around her right eyelids.

Neck: Symmetrical neck. Trachea is midline. Thyroid isthmus barely palpable, lobes not felt. No lymphadenopathy. Full ROM. No bruits noted. No signs of JVD distention. No goiter noted.

Pulmonary: Symmetrical chest wall. Normal chest expansion and excursion. Breath sounds clear to auscultation bilaterally. No adventitious breath sounds heard. No scars or lesions. Bilateral tactile fremitus. Diaphragms descends 4cm bilaterally.

Cardiovascular: S1 and S2 normal. No signs of S3 or S4 heart sounds. No edema. Capillary refill 2 seconds, pulses are equally 2+ bilateral. Regular heart rhythm. No murmur or signs or bruits. No edema observed.

Breast: No breast mass noted. Nipples are non-inverted, no discharge, and no signs of scaling.

GI: Abdomen soft and normal abdominal distension. No lesions. No bruits. Normal bowel sounds in all four quadrants. No CVAT tenderness. Liver span 7cm on the right midclavicular line, the edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not palpable.

Female genital: The pelvic exam revealed erythema and edema of the labia and vulva (Jeanmonod & Jeanmonod, 2020).

Neuro: Mental Status: Alert, oriented x4. Speech clear and thoughts are coherent. Cranial nerves: II-XII intact. Motor: Good muscle bulk and tone. Strength 5/5 in all extremities. Cerebellar: Normal posture. Steady gait. Scoliosis not present. RAM and point-to-point movement intact. Sensory: Proprioception, vibration, fine touch, pinprick, vibration, stereognosis intact and temperature all normal responses. Reflexes: Brachioradialis and biceps reflexes 2+ bilaterally. Patellar reflex 2+ bilaterality.

Musculoskeletal: No tenderness to palpation. No joint deformities. Good ROM in hands, wrists, elbows, shoulders, spine, hips, knees and ankles. Normal gait.

Psychosocial: Appropriate affect and mood.

Significant Data/Contributing: Unusual vaginal discharge and erythema and edema of the genitalia.

Assessments

Differential Diagnoses

1. Trichomoniasis

2. Chlamydia

3. Gonorrhea

Principal Diagnoses

1. Vulvovaginal candidiasis (Onset)

2. Bacterial vaginosis

Plan

Diagnosis: Vulvovaginal Candidiasis (vaginal yeast infection)

Diagnostic Testing: Papsmear to test vaginal secretions to establish the kind of fungus causing the infection.

Pharmacological Treatment: Fluconazole 150 milligrams single dose (Jeanmonod & Jeanmonod, 2020).

Education: Bathing daily with lots of water and minimal, unscented soap may help prevent recurrent infections (Schuiling & Likis, 2016). Wear cotton underwear urinate after sexual intercourse and shower.

Referrals: No referral needed.

Follow-up: Follow-up was scheduled for one week to discuss results.

Anticipatory Guidance: Completing the full course of treatment prescribed is essential, good hygiene is important, avoid tampons during treatment.

Diagnosis: Bacterial vaginosis

Diagnostic Testing: Papsmear to test vaginal secretions to establish the kind of fungus causing the infection.

Pharmacological Treatment: Metronidazole 500 mg orally twice a day for 7 days OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, daily for 5 days (Schuiling & Likis, 2016).

Education: Bathing daily with lots of water and minimal, unscented soap may help prevent recurrent infections (Schuiling & Likis, 2016). Wear cotton underwear urinate after sexual intercourse and shower.

Referrals: No referral needed.

Follow-up: Follow-up was scheduled for one week to discuss results.

Anticipatory Guidance: Completing the full course of treatment prescribed is essential, good hygiene is important, avoid tampons during treatment.

Signature (with appropriate credentials): MSN, APRN, FNP-Student

Cite Current Evidenced Based Guideline(S) Used To Guide Care (Mandatory)

Recording the subjective assessment provided vital data concerning the presenting disorder. Establishing the “onset, location, duration, characteristics, aggravating and relieving factors, and treatment (OLDCART)” was imperative to comprehending the prognosis of the disorder. Defining whether KP was taking any medication and family planning methods was important to determine possible causes and potential interactions. Utilizing the GTPAL system was imperative to gathering complete obstetric history. Developing a differential diagnosis was vital to defining the most probable cause to guide diagnostic plans. According to Jeanmonod and Jeanmonod (2020), prescribing fluconazole 150 milligrams single dose was imperative to help clear the yeast infection.

DEA#: 101010101 STU Clinic NPI# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: K.P Age: 25 years old

Date: March 22nd, 2021

RX: Fluconazole 150 milligrams single dose

SIG: 1 single dose

Dispense: Refill: 0

No Substitution

Signature: MSN, APRN, FNP-Student

References

Jeanmonod, R., & Jeanmonod, D. (2020). Vaginal Candidiasis. StatPearls [Internet].

Mbim, E. N., Mboto, C. I., George, U. E., Umego, C. F., Edet, U. O., & Orajiaka, N. A. (2017). Prevalence of vaginal candidiasis among female students of a hostel in the University of Calabar, Calabar. Journal of Applied Life Sciences International, 1-7.

Schuiling, K. D., & Likis, F. E. (2016). Women's Gynecologic health thrid edition. Jones & Bartlett Learning.