soap note

Name:  W.F.

Date: 6/12/17

Time: 1430

Age: 58

Sex: F

SUBJECTIVE

CC: 

“I have vaginal itching and burning, earache, and sore throat”

HPI: 

W.F. is a 58 y/o white female with a history of vaginal itching and burning.  She was treated in October 2014 with Acyclovir for r/o genital herpes.  She was instructed to follow-up with primary physician but she did not due to “not being able to afford it”.  She states the vaginal irritation did not completely alleviate but was getting better for a while.  Patient states pain got better but now has been experiencing increased itching for the last four days.  States she has been using Aveeno lotion to soothe the itching and burning but it is no longer working.  Denies internal vaginal itching and irritation.  Also denies any associated symptoms.  Patient report ear pain x 2 weeks with notice of sore throat off and on since last night.  Describes throat as scratchy without cough.  She denies any use of OTC medication to treat sore throat or ear pain.

Medications: Ibuprofen 1-2 tabs prn for minor aches

PMH

Allergies:  None

Medication Intolerances: None

Chronic Illnesses/Major traumas: History of cocaine drug use.

Hospitalizations/Surgeries: Denies any hospitalizations outside of vaginal birth 31 years ago. Tonsillectomy as a child

Family History

W.F.’s parents are deceased. Her mother died in 2006 from heart disease and she is unsure of the reason for father’s death in 2010.  Maternal grandmother is deceased from massive heart attack and unsure of maternal grandfather and paternal grandparents cause of death.   She has one living brother in Alabama that may have diabetes.  W.F. has one daughter that lives three hours away with no health problems. 

Social History

Patient is single and never was in a relationship with the father of her child.  She is not in a relationship at this time.  She is a GED graduate that now works as a housekeeper in environmental services.  Patient admits to cocaine drug use but has been clean through self-detox for the last 15 years.  She admits to pack/day cigarette smoking and admits to social alcohol drinking less than three times per month.  Attends church on occasions.  States she gets along well with co-workers but is mainly friends with two of her neighbors.  No immediate family in the area.  She participates in employer health plan.

ROS

General

Denies weight change.  “I work 24-30 hours per week, I am always tired”.  Denies fever or chills

Cardiovascular

Denies chest pain, palpitations, or edema 

Hair, Skin, and Nails

Vaginal rash, none on other body parts

Respiratory

Denies cough, wheezing, SOB

Eyes

Denies visual changes; wears glasses. Dark circles under eyes from vaginal itching awakening

Gastrointestinal

Denies abdominal pain, n/v/d, or bowel changes. Denies black stools

Ears

Denies hearing loss or tinnitus; outer ear pain x 2 weeks; denies trauma but sore on left ear

Genitourinary/Gynecological

Denies dysuria, hematuria, urgency or frequency. Admits to vaginal itching and burning x 4 days. Denies sexual activity. Denies vaginal odor or excessive discharge

Nose/Mouth/Throat

No Sinus problems, nose bleeds or discharge. Scratchy throat. Denies dysphagia or hoarseness

Neurological

Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

Lymphatics

Small knot behind ear

Psychiatric

No diagnosis.  Some depression at times. No suicidal ideations. Difficulty sleeping when experiencing vaginal irritation.

OBJECTIVE

Weight: 211       BMI 38.6

Temp 98.6

BP 138/88

Height 62”

Pulse 66

Resp 18

General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.

Skin

Skin is warm and dry, clean and intact. No rashes or lesions noted. Age appropriate wrinkles noted.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. Sclera and conjunctiva clear.  Small amount of edema to lower eyelids with dark circles. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Three healing scars/sores less than 0.5cm in diameter noted to left external ear and helix. Denies painful palpation of helix, auricle, or pinna. Nose: Nasal mucosa pink; normal turbinates. No septal deviation or discharge. Neck: Supple. Post auricular lymph node, non-tender, less than 0.2cm. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth decay noted

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and non-labored; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. 

Genitourinary

Bladder is non-distended; no CVA tenderness. External genitalia reveals no pubic hair from grooming; no lesions noted but external brownish rash to labial minor and major. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink. Scant clear to white discharge noted.

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in work uniform. Maintains eye contact. Speech is clear and normal rate. Answers questions appropriately.

Lab Tests

Urinalysis – No ketone, nitrites, or WBCs

Special Tests: none

 Diagnosis

 Differential Diagnoses

· 1-Vaginitis- usually involves inflammation. It can result in discharge, itching, and pain (Mayo Clinic, 2015).

· 2-Hypersensitivity- allergy or contact dermatitis is a possible cause of vaginitis symptoms.  Feminine hygiene products, soaps, clothing detergents, bubble bath are some offending agents (Buttaro, Trybulski, Bailey, & Sandberg, 2015; Cash & Glass, 2014).

· 3- Trichomonas- the presenting complaints are discharge and itching. It can be differentiated from yeast the discharge, which is usually thin and frothy rather than thick discharge of yeast (Goolsby & Grubbs, 2015)

Diagnosis: 112.1 Candidias- Goolsby & Grubbs, 2015 suggest that intense vulvar itching can accompany a discharge. Inflammation can cause dyspareunia and burning of the labia

Plan/Therapeutics

· Plan: 

· Further testing- if symptoms are not relieved within 1 to 2 weeks then the patient instructed to follow-up for possible GYN referral (Buttaro et al., 2013)

· Medication-Nystatin cream to external vagina BID X 7 days (Cash & Glass, 2014)

·  Bactrim DS BID 7 days PO

·   Diflucan 150mg PO after antibiotic completion (Buttaro et al., 2013)

· Education: Patient educated to not use douches and stringent detergents. Do not use any lotions or soaps to vaginal areas, no tight clothing, and wear cotton underwear (Buttaro et al., 2013).  Do not scratch and keep nails short.  Patient also needs to complete all antibiotics.

 Evaluation of patient encounter:  I felt comfortable addressing this patient complaint.  However, I was able to assess the patient and she felt like the education was going to be beneficial.  This patient was shaving every other day. So being aware of some of the non-pharmacological interventions was helpful.