NSG6435 Week 9 SOAP Hughes S

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South University, Savannah *

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6435

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Chemistry

Date

Jan 9, 2024

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CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes Student Name: Stephanie Hughes Course: NSG 6435 Patient Name: E.S. Date: 11/17/2023 Time: 11:44 am Ethnicity: AA Age: 15 Sex : F SUBJECTIVE (must complete this section) CC : Pt states, “I possibly have a yeast infection. It has been itchy with discharge x3 days.” HPI : E.S. presents with her mother with the c/o vaginal itching. She describes it as itchy with dysuria. The onset was 3 days ago. The pt verbalizes the onset was gradual and ongoing. E.S. stated, “It bothers me all day long with no relief.” The patient describes the discharge as white non odorous. She denies being sexually active. States her last menses was on 11/9/2023. Medications : None Previous Medical History: None Developmental History: E.S. is an overall well developed 15-year-old female. She was born at 37 weeks’ gestation via c-section. E.S. is very Intune with her own body. She is physically mature and completed puberty. E.S. can form her own thoughts and opinions. She is self-sufficient per the mother and works a job after school at chick-fi-la. The patient feels confident about her body imagine. Allergies: NKA Medication Intolerances: NKDA Chronic Illnesses/Major traumas: None Immunizations: Up to date on Immunizations mother declined flu vaccine for the year of 2023 Hospitalizations/Surgeries: None Health Promotion/Health Maintenance: E.S. should be encouraged to get at least 8-10 hours of sleep per night. E.S. should be encouraged to have meals with the family at the table. By during this it will help her make healthy eating habits, better food choices, and help with promotion of a healthy weight. This time with the family also allows family members to talk and discuss currents events together. Teenagers that eat with their family are more likely to make better grades in school. She will be less likely to engage in illicit drug use, smoking, or drinking. This will also make her less likely to engage in argumentized confrontations with peers, decrease suicidal ideations, and reduce the chances of sexual engagement. There should be family guidelines on screen time such as television, cell phone use, and other devices. It would be helpful to have a family media plan, so as a parent the child’s social media can be closely monitored. E.S. should be getting at least 1 hour of physical activity. Nutrition: E.S. should be eating a diet that is rich in whole grains, veggies, fruits, and milk products that are low far or no fat. Her diet should also include beans, fish, lean meat, and eggs. This will ensure that she is taking in the right amount of nutrients. Diet: Regular diet

Exercise: E.S. should be getting at least 1 hour of physical activity daily . Regimen: The patient stated she goes to Planet Fitness with her friend and friends’ mother about three times per week so they can work out. Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: The patient is not exposed to any of the following in question. The patient denies the use of any of the following in question. Safety Measures: E.S. is at the age where the mother was educated that she needs to talk with her daughter about safety measures with driving. As MVA’s are one of the leading causes of unintentional deaths among teens. The mother was also educated on talking with her daughter about suicide and signs to look for as it is ranked the 3 rd leading cause of death for the ages of 15-24 years of age. It was discussed with the mother that she should talk with her daughter about sexual activity and have E.S. tell her what she knows about having sex. She should also have the same conversation with her about drugs, alcohol, and smoking. I explained to the mother to be open and listen to her, and it was ok to provide her feedback, but she needed to be honest and direct when answering any questions. I also spoke with E.S. about making sure that she picked her friends wisely and not friends that act out in any dangerous manner. I also spoke with the patient and mother about making sure boundaries are in place for how and when they will communicate with each other for check in, and that there is parental supervision when E.S. is away. It was also discussed about setting curfew and consequences if the rules are not followed. Screening exams: E.S. had her yearly well child checkup back in June. During that time, she had her height, weight and BMI calculated. She also had her spinal curvature checked and it was normal. She was noted to be up to date on her immunizations. She had a UA completed and Hgb check in office during the visit. She was also provided with outpatient lab orders for the mother to take the patient for lab collection of anemia, cholesterol levels, TB, and STD screening. It was explained that it wasn’t required but recommended at her appointment. F AMILY HISTORY (must complete this section) M : No significant history MGM: HTN and Hyperlipidemia MGF : DM F : HTN PGM: No significant history PGF: Deceased Social History: The patient lives at home with her mother but has a relationship with her father. She is the only child and attends high school with good grades. She is employed part-time at Chick-fi-la. E.S. states that she is saving up for a car. She also stated that she has a great network of friends and gets along well with others. REVIEW OF SYSTEMS (must complete this section) General : C/O vaginal itching with white discharge and dysuria x3days. Cardiovascular : Denies chest pain or palpitations Skin : Denies any rashes or lesions. Denies any open areas or unhealed wound to the skin. Respiratory: Denies feeling SOB or cough Eyes : Denies any visual changes. Denies requiring glasses or contact lenses. Gastrointestinal: Denies any abdominal pain, nausea, or vomiting Ears : Denies any hearing complications Genitourinary/Gynecologica l: C/O dysuria with vaginal itching and white discharge x3 days. Denies any foul-smelling odor. Verbalized LMP 11/9/2023 Nose/Mouth/Throat: Denies any complications with his sinuses, dysphagia, or sore throat Musculoskeletal: Denies any joint or muscle pain

Breast: Denis any changes in breast Neurological : denies any headaches, neck pain, weakness, or syncope Heme/Lymph/Endo: Denies any complications with diet and denies any malaise Psychiatric : Denies any anger or thoughts of suicidal ideation OBJECTIVE (Document PERTINENT systems only, Minimum 3) Weight : 153 lbs Height : 5’6” BMI : 24.7 BP: 112/70 Temp : 98.9 F Oral Pulse: 70 bpm Resp : 14 bmp SPO2 %: 98% RA General Appearance: Overall: well, developed, in no acute distress and well nourished Skin : Defer HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex. Nose: Nasal internal turbinate’s non-erythematous. No septal deviation. Neck: Supple. Full ROM; The cervical anterior and posterior lymph nodes are non-tender bilaterally upon palpation; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Tonsilopharyngeal area non-erythematous. Oropharyngeal no drainage noted. Teeth are in good repair. Cardiovascular: No gallops, no rubs, regular rate, normal heart sounds no murmurs. Respiratory : Respirations even and unlabored. Lungs clear to auscultation anterior and posterior bilaterally. Gastrointestinal: Defer Breast : Defer Genitourinary : The patient complains of white vaginal discharge with itching and dysuria. She denies urinary incontinence, flank pain, hematuria, or nocturia. No bladder tenderness on palpation. No costovertebral tenderness upon exam. Musculoskeletal: Defer Neurological: Defer Psychiatric : Defer Diagnostic Studies: UA completed in office: Dip stick was positive for WBC, Leukocytes, and Nitrites. UCG completed in office: Negative Special Tests: Urine sent out for C&S 06062023 Page 1 of 2 C ONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Note s DIAGNOSIS (must complete this section) Differential Diagnoses • Vaginal Yeast Infection, B37.3 (Eckert, 1998) • Bacterial Vaginosis N77.1 ("Vaginitis in Nonpregnant Patients," 2020) • Cystitis N30.90 ( Bent, 2002) Diagnosis • UTI N39.8 (Edlin et al., 2013)

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Plan/Therapeutics: Medication  Bactrim DS 800 mg- 160 mg tablet, take 1 tablet po BID x7 days for a total of 14 doses.  Fluconazole 150 mg tablet, take 1 tablet po x 3day. Non-Medicated Treatment  Increase water intake  Avoid baths if possible  Wearing cotton under garments  Keep the perineal area clean and dry  Ensuring wiping from front to back  If sexually active to always have protective sex; however abstinence is the best preventative measure. Diagnostics: Education Provided: The patient and mother were educated on UTI, and discussed making sure she completes her full dose of antibiotic therapy and taking OTC ibuprofen/Tylenol prn for pain. I also instructed the mother that she could purchase OTC AZO for the painful urination. The patient was educated on increasing her water intake. Education was provided on providing good perineal hygiene. Ensuring that she is wiping from front to back. To wear cotton under garments, avoid baths if possible, keeping her perineal area clean and dry. The mother was educated that we would send her urine out for a culture and sensitivity, and if anything resulted that the antibiotics prescribed would not cover then we would call her in a different antibiotic and follow up with her about the change in medication. The mother and patient were instructed to return to the office in 2 weeks for a follow-up or prn if needed to be seen sooner. The mother and patient verbalized understanding. 06062023 Page 2 of 2