NSG 6430 Week 9 Soap Note Meissner D

Surgeries: CONPH NSG6330/NSG6430 Subjective, Objective, Assessment, Plan (SOAP) Notes Student Name: Dina Meissner Course: NSG 6430 Patient Name: (Initials ONLY) NM Date: 11/14/23 Time:0830 Ethnicity: White Age: 45 Sex: Female SUBJECTIVE (must complete this section) CC" I have been experiencing thin white discharge that has been itchy” HPI: The patient is a 45-year-old female G4P3 who presents to the office c/o thin white discharge for the past 3 weeks. Pt has a medical history of HTN, GERD, and HLD. Pt denies being sexually active. Pt reports doing an at home UTI test which came back negative. Pt reports a strong odor from the discharge as well as some vaginal itching. Medications: Amlodopine 10 mg once a day, Omeprazole 40mg once a day, Atorvastatin 20 mg once a day Previous Medical History: Allergies: None Medication Intolerances: None Chronic Illnesses/Major traumas : HTN, GERD, HLD Hospitalizations/Surgeries: C section in 2006 FAMILY HISTORY (must complete this section) M: Living, HTN MGM: Passed away, CKD MGF: Living, dementia F: Living, HTN, Dm2 PGM: Died from cardiac arrest PGF: Died from colon cancer Social History: patient is a 45 year old female who is divorced and is busy with her 3 kids and taking care of her parents. She reports having a good social network and reports drinking socially and denies any smoking or illicit drug use. . REVIEW OF SYSTEMS (must complete this section) General: Pt is alert and oriented x4. No fever or chills. Cardiovascular: de nies any cp or palpitations, syncope, or orthopnea Skin: No bumps, lumps or lesions present Respiratory: Denies any shortness of breath Eyes: no vision changes or corrective lenses Gastrointestinal: denies any cp or palpitations, syncope, or orthopnea Ears: Denies any ear pain, hearing loss or ringing in the ears Genitourinary/Gynecological: Pt reports thin white vaginal discharge that is malodorous Nose/Mouth/Throat: Denies any pain. No redness or swelling Musculoskeletal: Denies any knee back or joint pain Breast: no lumps bumps or changes Neurological: no acute or chronic neurological changes Heme/Lymph/Endo: no lymphadenopathy noted Psychiatric: no phsychiatric history OBJECTIVE (Document PERTINENT systems only, Minimum 3) Weight: 150lb Height: 5”3” BMI: 26.6 BP: 122/68 Temp : 98 Pulse: 77 Resp: 22 General Appearance: pt is normal weight and in no acute distress. She appears well groomed and well taken care of Skin: Skin is tan, warm, dry, clean and intact. No rashes or lesions noted. HEENT : The head is normal-shaped. PERRLA eyes, anicteric sclera, no conjunctival pallor, and supple neck. complete range of motion, no cervical lymphadenopathy, and no occipital nodes. neither nodules nor thyromegaly. Pink and moist oral mucosa. No tumors or dental anomalies in 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 are regular and easy; lungs clear to auscultation bilaterally Gastrointestinal: symmetrical with normal bowel sounds in each of the four quadrants. Soft abdominal wall, no distention, and slight epigastric discomfort. No sensitivity for rebounding or defending. Hernia, hepatosplenomegaly, or no masses. Breast: breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin. Genitourinary : Upon examination thin white malodorous vaginal discharge noted. Musculoskeletal: While observing the patient move about the examination room, full range of motion was noticed in all four extremities. No cyanosis or clubbing or edema. The skin and extremities appear to be well-perfused . Neurological: Speech clear, balance stable, good tone Psychiatric: o riented and alert. capable of keeping eye contact. Lab Tests: Urinalysis – negative for UTI. Special Tests: Whiff test – positive for bacterial vaginosis, Vaginal swab for yeast - Negative DIAGNOSIS (must complete this section) Differential Diagnoses • Diagnosis, (ICD 10 code and reference): Urinary tract infection (N39.0) UTIs are frequent illnesses that develop when bacteria enter the urethra and infect the urinary tract. These germs are frequently from the skin or rectum. The infections can affect different regions of the urinary tract, but a bladder infection (cystitis) is the most typical kind (Czajkowski et al., 2021) . • Diagnosis, (ICD 10 code and reference:)2- Bacterial Vaginosis (N76.1) A bacterial imbalance results in bacterial overgrowth, which leads to bacterial imbalance and bacterial vaginosis (BV), a common vaginal infection. A "fishy"-smelling vaginal discharge that is off-white or gray is one of the symptoms. With the help of antibiotics from a medical professional, BV is easily curable (Abou Chacra et al., 2022). • Diagnosis, (ICD 10 code and reference:) 3 – Yeast infection (B37.3) a vaginal yeast infection that affects the vulva's opening tissues. The fungus candida is what causes this particular sort of yeast infection. Inflammation, severe itching, and a thick, white discharge from the vagina can all be symptoms of this illness (Sprute et al., 2021). Diagnosis • Presumptive diagnosis (ICD 10 code and reference): Bacterial Vaginosis (N76.1) Plan/Therapeutics: : Additional testing — The patient was prescribed Flagyl 500mg PO BID for 7 days to treat the bacterial vaginosis (Abou Chacra et al., 2022). Diagnostics: Urinalysis, whiff test, and yeast infection swab Education Provided: e): Even though the symptoms of BV go away after a few doses of treatment, patients should still finish the complete course of therapy. This is one of the greatest strategies to lower the risk of BV recurring. Condoms should be used regularly and correctly for all forms of sexual activity. Avoid doucing. Douching is the practice of rinsing the vagina with a solution. Douching has not been proved to be advantageous. Douching can throw off the vagina's normal bacterial balance, which could lead to the flushing of dangerous germs into the higher genital tracts (Abou Chacra et al., 2022).