Gynecologic Health

Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note 1 OR 2 PAGES :

 

Subjective: What details did the patient provide regarding her personal and medical history?

 

Objective: What observations did you make during the physical assessment?

 

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

 

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters for this patient , as well as a rationale for this treatment and management plan.

 

Very Important:  Reflection notes: What would you do differently in a similar patient evaluation?

 

 

 

Reference

 

Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.

 

Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.

 

 

 

Chapter 6, “Care of the Well Woman Across the Life Span” ,“Care of the Woman Interested in Barrier Methods of Birth Control” (pp. 275–278)

 

Chapter 7, “Care of the Woman with Reproductive Health Problems”

 

“Care of the Woman with Dysmenorrhea” (pp. 366–368)

 

“Care of the Woman with Premenstrual Symptoms, Syndrome (PMS), or Dysphoric Disorder (PMDD)” (pp. 414–418)

Week 3 Soap Note: Bacterial Vaginosis

Bethel U. Godwins

Walden University

NURS 6551, Section 8, Primary Care of Women

June 17, 2016

Week 3 Soap Note: Bacterial Vaginosis

Patient Initials: WJ Age: 22 Gender: Female

SUBJECTIVE DATA:

Chief Complaint: “I have vaginal itching with discharge and foul odor for the past one week ”

History of Present Illness: WJ is a 26-year-old Hispanic American female who presented to the clinic with complaint of vaginal itching with thin, gray vaginal discharge. Patient reported that the vaginal discharge has a strong foul, fishy odor, and the vaginal odor was particularly strong with a fishy smell after sex for the past one week. Patient stated that she has burning on urination, but denied fever, chills, nausea or vomiting. She reported that she decided to see a health care provider because she could not tolerate the odor, burning and discharge anymore.

Location: Vaginal

Duration: One week.

Quality: Itching, gray vaginal discharge; strong foul odor with fishy smell

Radiation: None

Severity: 8/10 on a scale of 1 to 10.

Timing/Onset: One week ago, but worse in the past 2 days.

Alleviating Factors: None

Aggravating Factors: sexual intercourse

Relieving Factors: Sitz bath

Treatments/Therapies: None except warm sitz bath

Medications: None

Allergy: No known drug or food allergy.

Past Medical History: None

Past Surgical History: None

GYN History: LMP 06/09/2016; last Pap smear 05/2016; result: WNL; menarche 12; cycle 5 days; age of first intercourse 18 year; number of partners one; no contraceptive, heterosexual.

OB History: Gravida: 0 Para: 0

Personal/Social History: Single; denied recreational drug/alcohol use. Lives alone. Sexually active.

Immunizations: up to date with vaccination; positive influenza vaccine in November 2015. Negative Pneumococcal vaccine.

Family History: Diabetes: father; hypertension: Mother; both parents still living .

Review of Systems:

General: Patient appeared well nourished; active, denied change in weight .

HEENT: Patient denies headache or head injury, wears contact lenses, denies nasal/sinus congestion or drainage. Denies hearing problem, tinnitus or vertigo. H e reports that he had his dental exam within the last 6 months, and denies any bleeding gums, gingivitis or ulceration lesions; denies chewing or swallowing problem.

Neck: Denies neck pain, tenderness, swelling, or neck injury.

Respiration: Denies difficulty breathing, cough or coughing up blood, or dyspnea at rest .

Cardiovascular: Denies chest pain, SOB, palpitations, edema, arrhythmias, and heart murmur. Gastrointestinal: Denies abdominal pain, nausea, vomiting, or changes in bowel/bladder regularities. Admits good appetite.

Peripheral Vascular: denies any peripheral vascular problem .

Urinary: Reports burning on urination, denies back pain, frequency, blood in the urine.

GYN: Reports vaginal itching with thin, gray vaginal discharge. Reports vaginal discharge with strong foul, fishy odor; reports vaginal odor particularly strong with a fishy smell after sex, denies STDs.

Musculoskeletal: Denies joint pains, joint stiffness, or problem with joints range of motion.

Psychiatry: Denies anxiety, depression, mood changes, and mental health. Denies any suicidal ideation or attempt.

Neurological: Denies memory loss, dizziness, tingling/numbness, falls, and seizures.

Integument/Hematology/Lymph: Denies bruising easily, skin rashes, dryness, itching, skin lesions and cancer. Denies any clotting or bleeding disorders. Denies transfusion reaction.

Endocrine: Denies diabetes, thyroid problem, heat or cold intolerance.

Allergic/Immunologic: Denies allergic rhinitis, denies immune deficiencies.

OBJECTIVE DATA

Physical Exam:

General: Alert and oriented. Appeared well-groomed. Patient does not appeared to be in any acute distress. Vital signs: B/P 116/74, left arm, sitting; P 76; RR 18; SPO2 100% RA. Weight 132 pounds, BMI 20.53, Height 65 inches.

HEAD: Head round and symmetry, no lesions, bumps, nodules, or injury noted.

EENT: PERRLA, clear conjunctiva and sclera; hearing intact bilateral; TMs visualized, pearly grey; clear nasal passage, normal turbinates, septal deviation absent. Oral mucosa pink and moist .

Neck: thyroid supple, midline trachea, no thyromegaly or lymphadenopathy

Chest/Lungs: Chest wall symmetrical, no use of accessory muscles note, breath sound are clear to auscultation, no wheezing, rhonchi, or prolonged expiration noted in the upper/lower lung fields. No nipple discharges or abnormal lump noted.