Diagnostic Reasoning Case Study

Diagnostic Reasoning Case Study Jennifer Hood University of Texas Arlington College of Nursing and Health Innovation Nursing 5333 Family Nursing I Kashiris Perryman, DNP, APRN, FNP-PC June 12, 2021 Soap Note S/ Identifying Information: Martha 26 yo female DOB July 12, 1995 Family Hx: Mother--DM (Alive) Father—COPD (Alive) Brother—No preexisting conditions (Living) Personal/Social Hx: Chief Complaint/RFE: College Graduate Currently employed as a schoolteacher Financially secure Lives alone in apartment Feels safe at home and in current relationship Heterosexual Monogamous relationship with boyfriend Denies smoking and drug abuse Socially drinks: 1-2 glasses of wine/weekend vaginal burning x 3 days Hx Present Illness: 26 yo female comes into clinic today in no acute distress. Reports vaginal burning for the last 3 days. Is sexually active and last sexual intercourse was one week ago. CURRENT HEALTH Medications: No Medications, vitamins, or herbal supplements Allergies: NKDA. Seasonal allergies in the Spring Last PE & Screenings: Last PAP 2016 (age 21): Negative Immunization Status: Has not received HPV vaccine LMP & Birth Control (if applicable) PMH Illnesses & Trauma: None Hospitalizations/Surgeries: tonsillectomy 2002 (age 7) OB Hx/Sexual Hx: Sexually active since age 15. Has had 2 relationships this past year. Last sexual intercourse: 1 week ago Emotional/Psy Hx: REVIEW OF SYSTEMS General Denies fever, chills, nausea, vomiting, and diarrhea Nutrition defer Skin/Hair/Nails defer HEENT defer HEAD – EYES— EARS-- NOSE— THROAT-- Breasts defer Respiratory defer CV/peripheral vascular defer GI defer GU Vaginal burning, dysuria, large amount of foul smelling vaginal discharge; first occurrence, dyspareunia. Denies use of vaginal sprays, douches, or powders or use of new soap, detergent, or clothing. Wears thong underwear MSK defer Psych defer Neuro defer Lymph/Heme/Endocrine defer O/ PE: T: 98.6 P: 64 R: 18 BP: 110/70 HT: 160 cm WT: 54.4 kg BMI: 21.25 General appears to be slightly anxious but pleasant and cooperative Skin defer Head defer EENT EYES-- EARS— NOSE-- THROAT— Neck defer Breasts/Chest defer Lungs RLL clear to all lung fields Heart/ peripvascular RRR, no murmurs auscultated Abdomen soft, no distension, nontender, no organomegaly Genitalia/Rectum vaginal mucosa moist and pink with mild edema. Copious discharge in introitus with foul odor. Cervix pink and friable. Chandler sign (-). pH mild alkalinity, wet prep shows trichomads Lymph no swelling or tenderness noted to inguinal LNs MSK defer Neuro defer