NSG6420 Week 9 SOAP

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South University, Savannah *

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6420

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Chemistry

Date

Feb 20, 2024

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docx

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SOAP NOTE Student Name: Course: NSG6420 Name: Date: 02/01/2024 Time: 1545 Ethnicity: Hispanic Age: 32 Sex: F SUBJECTIVE CC: “I have been having white cottage like vaginal discharge and itching” HPI: A 32-year-old Hispanic female, presents with a chief complaint of white cottage-like vaginal discharge and itching persisting for the past week. She describes the discharge as a novel occurrence and notes no associated foul odor. The patient reports a regular menstrual history, denies recent changes in hygiene or sexual activity, and is in a monogamous relationship. She has not used any vaginal products or medications and has no history of sexually transmitted infections or recent antibiotic use. Seeking relief from the discomfort, she has not attempted self-treatment and hopes for a thorough evaluation to determine the cause. Medications: (list with reason for med ) Albuterol Inhaler 90mcg PRN PMH Allergies: NSAIDS- Shortness of breath Medication Intolerances: None Chronic Illnesses/Major traumas: Asthma Hospitalizations/Surgeries- N/A Family History M: Alive- pre-diabetes

MGM: Alive- unknown MGF: Alive unknown F: Alive- hypertension PGM: Alive- unknown PGF deceased- unknown Social History Patient reports being in a monogamous relationship with her husband and does not engage in high-risk sexual behaviors. Ms. Rodriguez resides in a suburban setting and is employed in a clerical position. She denies usage of drugs, alcohol, or nicotine. ROS General Patient denies night sweats, fatigue or weakness Cardiovascular Denies any chest pain or shortness of breath, Skin No rash, lesions, or other skin abnormalities Respiratory Denies dyspnea denies cough. Eyes Denies any visual changes Gastrointestinal Denies abdominal pain, nausea, vomiting or diarrhea Ears Denies ear pain or hearing loss Genitourinary/Gynecological Reports white discharge and irritation

Nose/Mouth/Throat Denies loss of smell, sore throat, nasal discharge, and congestion Musculoskeletal Denies pain Breast Denies pain or discomfort Neurological Denies syncope, seizures, headache, or dizziness Heme/Lymph/Endo Denies bleeding, no enlarged lymph nodes Psychiatric Denies depression, anxiety, SI or sleeping difficulty OBJECTIVE Weight 66g BMI 23.37 Temp 37.1 BP 107/80 Height 5’6 Pulse 77 Resp 16 General Appearance The patient appears well-groomed and in no apparent distress, demonstrating a calm demeanor and cooperative attitude during the encounter. Skin Skin in clean, dry and intact. HEENT Head is normocephalic, atraumatic. Eyes: Pupils are equal, round, and reactive to light, vision grossly normal. Ears: Canals patent. Bilateral tympanic membranes clear, landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Tenderness present on palpation at the sinus maxillary and frontal sinus Neck: Supple. Full ROM; trachea midline. Mouth/throat: Oral mucosa is moist and pink. Teeth are in good repair . Pharynx appears pink without any erythema or exudate. The uvula is midline. The tonsils are without enlargement or evidence of inflammation. Cardiovascular Normal rhythm and rate, characterized by clearly audible S1 and S2 heart sounds. No additional auscultatory findings, including murmurs, rubs, or clicks, are noted. Absence of edema is observed, and pulses are uniformly assessed as 3+. Capillary refill time is measured at a brisk two seconds. Respiratory Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal Gastrointestinal Abdomen is symmetrical and slim, soft, non-tender, no guarding or rebound tenderness, bowel sounds present in all four quadrants Breast

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Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin . Genitourinary/gynecological Labia is inflamed, white thick discharge present in the vagina. Bladder appears relaxed without signs of distension; no CVA tenderness Musculoskeletal Full ROM Neurological Alert and oriented to person, place, time and situation, no focal neurological deficit observed, normal sensory observed, normal motor observed, normal speech observed Psychiatric Cooperative, appropriate mood and affect, maintains eye contact Lab Tests Urinalysis- Negative Special Tests Speculum exam: Genital culture Swab performed  Vaginal Discharge: The patient exhibited a white, cottage cheese-like vaginal discharge consistent with the reported symptoms.  Vaginal Wall Appearance: Signs of inflammation, including redness and mild swelling, were noted on the vaginal walls.  Cervical Appearance: The cervix appeared red and irritated, with an increase in mucus and discharge around the cervical os.  Yeast Clusters: White patches resembling yeast clusters were observed on both the vaginal walls and the cervix. Diagnosis  B37.9- Yeast Infection (Candidiasis) is a fungal infection caused by the

overgrowth of Candida species, predominantly Candida albicans, affecting various body parts such as the mouth, throat, genitals, and skin. Diagnosis involves clinical evaluation and may require laboratory confirmation. Treatment typically includes antifungal medications, and preventive measures involve addressing underlying risk factors (Willems et al., 2020). Differential Diagnoses N76.0-Bacterial Vaginosis is an imbalance in vaginal flora, often dominated by Gardnerella vaginalis. Symptoms include a thin, grayish-white discharge with a fishy odor and may involve itching or burning. Risk factors include multiple sexual partners and douching. Diagnosis is clinical, confirmed by elevated pH and clue cells. Treatment typically involves antibiotics like metronidazole or clindamycin to restore a healthy vaginal balance and prevent complications, especially in pregnant individuals (Kairys & Garg, 2023). A59.03-Trichomoniasis is a sexually transmitted infection caused by the parasite Trichomonas vaginalis. Symptoms include itching, burning, and a distinctive greenish- yellow vaginal discharge in females, and urethral discomfort in males. Transmission occurs through sexual contact, and those with multiple partners are at higher risk. Diagnosis involves laboratory testing, and treatment consists of oral antibiotics like metronidazole or tinidazole. Swift identification and management are essential to relieve symptoms, prevent complications, and curb transmission (Kissinger et al., 2022) . Plan/Therapeutics Plan  Prescribed Diflucan 150mg one time, if symptoms persist in 3 days take 1 more dose.  Hygiene Counseling: Perform gentle cleansing techniques and the avoid irritants such as scented soaps or douches that can disrupt the natural balance of the vaginal flora.  Patient educated on preventive measures to reduce the likelihood of recurrent yeast infections.  Patient to follow up in the clinic in 2 weeks Evaluation of patient encounter In our consultation with the patient, the healthcare provider and I thoroughly examined her medical history, with a particular focus on the progression of symptoms related to her yeast infection. We discussed the factors exacerbating and relieving her discomfort, as well as the impact on her daily activities. Exploring her current medication regimen, The patient actively contributed insights into managing her symptoms and shared her concerns. Towards the end of the consultation, she received a confirmed diagnosis of a yeast infection. Subsequently, the healthcare team recommended a tailored treatment

plan, including antifungal medication, hygiene counseling, and preventive education. The patient left with a clear understanding of her recent diagnosis and a well-outlined follow- up plan for monitoring her response to treatment. References Kairys, N., & Garg, M. (2023, July 4). Bacterial Vaginosis. In StatPearls [Internet]. StatPearls Publishing. Retrieved January 31, 2024, from https://www.ncbi.nlm.nih.gov/books/NBK4592 16/ Kissinger, P. J., Gaydos, C. A., Seña, A. C., McClelland, R. S., Soper, D., Secor, W. E., Legendre, D., Workowski, K. A., Muzny, C. A. (2022). Diagnosis and Management of Trichomonas vaginalis: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines. Clinical Infectious Diseases, 74(Supplement_2), S152– S161. https://doi.org/10.1093/cid/ciac030 Willems, H. M. E., Ahmed, S. S., Liu, J., Xu, Z., & Peters, B. M. (2020). Vulvovaginal Candidiasis: A Current Understanding and Burning Questions. Journal of fungi (Basel, Switzerland), 6(1), 27. https://doi.org/10.3390/jof6010027

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