Summary NR603 Week 5 SOAP Note

S: SUBJECTIVE DATA (CC): STI Check. “I’ve been having vaginal discharge, irritation, itching, and burning for 3 days”. (HPI): B.S. 29 y/o, Caucasian female who presents with vaginal irritation, itching, burning, and discharge for 3 days. Pain is described as intermittent dull/burning to vagina that is worse with urination, rates as 6/10. Nothing relieves the pain as nothing has been tried at home. Patient reports vaginal discharge that is thick and clear to yellow in color. She admits to having multiple unprotected heterosexual (vaginal sex only) encounters with 2 men within the last month. Denies history of previous STDs. Uses condoms most of the time but there have been some encounters which she did not use a condom. Currently not on any form of birth control. (PMH): Patient has no significant medical or surgical history, no known drug allergies, and does not take any medications. G1P1, last PAP exam was about 2 years ago and was normal. Immunizations are up to date, but she has not received the HPV vaccine. (FH): Noncontributory. (SH): Patient is single, employed as a customer service representative for a local company and lives in an apartment with her 6 y/o daughter. Denies smoking history, drinks alcohol socially on weekends, and denies illicit drug use. (ROS). Constitutional: denies fatigue, fever, chills, and weight loss/gain. HEENT: denies nasal discharge, sneezing, or tearing. CV: denies chest pain, dizziness, or shortness of breath. Resp: denies cough, shortness of breath, or congestion. GI: +lower abdominal pain. Denies nausea or vomiting. GU: LMP 7/25/2018. First period at age 13 with regular monthly cycles about every 30 days, admits to unprotected sex with 2 sexual partners. denies dysuria, urgency, frequency, blood in urine, pain with urination, +vaginal discharge, itching, burning, and dyspareunia. MUSCULOSKELETAL: denies muscle aches or weakness. SKIN: denies lesions or rashes. NEURO: denies numbness, tingling, or dizziness. PSYCH: denies anxiety, depression, or SI/HI. ENDO: denies heat or cold intolerance. LYMPH: denies bleeding, bruising, or infection. ALLERGIC: denies any allergies. 0: OBJECTIVE DATA PE: Constitutional: This is a 29 y/o female that is afebrile, with normal vital signs BP: 104/68 HR: 76 RR: 14 T: 98.1 O2: 98% RA Ht: 65 inches Wt: 132 pounds, BMI 20.53. Appears in no acute distress. She is alert and oriented x 3 with normal mood and affect. HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. No sinus tenderness. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink. No septal deviation. Neck: Supple. Full ROM. No lymphadenopathy, thyromegaly, or nodules. Oral mucosa pink and moist. Pharynx pink. Teeth are in good repair. Chest/Lungs: Chest wall symmetrical, no use of accessory muscles, breath sound clear to auscultation bilaterally in all fields. CV: S1, S2 noted with regular rate and rhythm. No clicks, rubs, or murmurs noted. Capillary refill less than 3 seconds. Pulses 3+ in all extremities. No edema noted. Abdomen: Abdomen is soft and nondistended without lesions or discoloration with normal bowel sounds present in all 4 quadrants. Tenderness noted upon palpation in right and left lower quadrant. No guarding or hepatosplenomegaly. Genital: External genitalia normal w/o lesions. Vulva erythematous, excoriated, and swollen. Vaginal mucosa pink with moderate amount of thick white discharge without odor present in vaginal canal. Cervix intact without lesions or tenderness. Uterus midline, mobile, and non-tender. No adnexal masses palpable. Specimens collected via swab for GC/Chlamydia and Trichomoniasis. Musculoskeletal: ROM intact in all extremities. Neurologic: Alert and oriented with normal affect and mood. Speech clear and organized; answers questions appropriately. Gait steady; able to move all extremities well. Sensations intact. Skin: Skin pink, warm, and dry with good turgor. No rashes, lesions, or ulcers. Labs: Urinalysis, Urine HCG, Urine C&S pending, GC/Chlamydia pending. Urine dipstick: 1+ bacteria, negative nitrites, negative leukocyte esterase, and no blood or ketones present. Urinary tract infection can be ruled out. Urine culture showed no growth. Urine HCG: Negative. Pregnancy should be ruled out initially because treatment will vary based on a positive or negative result. Point of care testing was not available so samples were sent out for nucleic acid amplification tests (NAATs). In women, NAATs can be performed on vaginal, endocervical, and urine specimens and is 3-5 times more sensitive in detecting infection compared to wet-mount microscopy (Hauk, 2016). GC, Chlamydia, BV, and Trichomoniasis all negative. Budding yeast noted on microscopic exam. A: ASSESSMENT: Vulvovaginal Candidiasis (B37.3) is caused by fungus candida, which causes vulvovaginal itching, burning, irritation, and thick white discharge that is often described as “cottage cheese” like in appearance and is usually odorless. BS reports vaginal itching, vaginal discharge, and irritation (CDC, 2016). Physical exam findings include thick white discharge that is without odor noted in vaginal canal during exam, erythematous, swollen, and excoriated vulva. Micro exam revealed budding yeast and was negative for GC, Chlamydia, BV, and Trichomoniasis making candidiasis the likely diagnosis. P: PLAN CDC recommends treating with topical or oral antifungals for uncomplicated infections. The azole drug class is preferred over nystatin as patients exhibit greater relief of symptoms with the azole. The recommendation is for a short course usually 1-3 days for uncomplicated infections (CDC, 2016). Patient preference should be considered when making treatment choices as many women do not like the mess of vaginal creams and prefer oral therapy. 1. medications Diflucan 150mg; Sig: 1 tab PO x 1 dose now. Dispense # 1, No refills. 2. additional diagnostic tests N/A 3. education Avoid sexual contact until infection is resolved. Relief will not be instant when taking oral Diflucan you can expect a gradual relief of symptoms over the course of 2-3 days after taking medication (Hollier, 2016). Side effects from medication are usually minimal but can include nausea, headache, and dizziness. Avoid tight fitting clothes, change out of wet undergarments as soon as possible, wear cotton underwear (CDC, 2016). 4. referrals N/A 5. follow up. Patient follow-up is not recommended in cases of candidiasis she should return if symptoms do not improve or become worse (CDC, 2016)