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

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—