Nurse Practitioner SOAP Notes

Nurse Practitioner SOAP Notes

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Nurse Practitioner SOAP Notes

Chief Complaint (CC): “In the past 7 days, I have had a very severe pain when urinating and a continuous feeling of scratching my private parts.”

History of present illness (HPI):  A 25 year old female by the name Topyster of Hispania origin comes to the hospital with her hands clinging on her pubic parts as a sign of severe pain. She claims that she has been feeling pain whenever she visits the toilet for a short call and this has been going on for the past one week. The lady reports severe pain while urinating and a feeling of itchiness in her pubic part every minute. She reports that she feels a lot of pain during sexual intercourse and this has caused a lot of discomfort to her partner. Asked whether she has ever used any medication to relieve this pain, she denies, saying that she does not know what type of medicine could help. She reported the pain extending to her periods and it became even worse when using the tampons and pads. The patient reported that she has never used a condom during sexual intercourse because they trust one another. The last menstrual period she received was in September 15th and during that time, the periods were accompanied with a lot of pain and the blood flow was more than usual.  The patient confirmed that she has never vomited nor felt nausea since the pain started.

OnsetThe pain started a week ago, on Wednesday
LocationAt the vagina
DurationWhen the pain started, it was not very severe; it used to occur after urination. As time went by, it became very severe and a feeling of scratching the vagina ensued.
CharacteristicsSharp pain during urination
Aggravating factorsUrination, sex
Relieving factorsSleep and cold bath
Treatments/ therapiesFluconazole, azole medicationhe, butoconazole (Gynazole-1), clotrimazole (Gyne-Lotrimin), miconazole (Monistat 3) and terconazole (Terazol 3).

Medications: the patient confirmed that she has been taking family planning pills.

Allergies: the patient has never experienced any allergy since her childhood, neither food nor environmental allergies reported.

Past Medical History (PMH): The patient confirmed that she has never been to hospital in the recent past.

Past surgical history: the patient has never undergone any surgery

OB/GYN history:

Obstetric history: she has one kid of 8lbs who she gave birth to on May, 2013 without any complications. The method of conception of the pregnancy was through sexual intercourse.

Menstrual history:  she started receiving her menstruations while she was 13 years old and the last period she received was on September 15, which lasted for 4 days. She has never used douching.

Sexual function: she is sexually active and the last sexual intercourse was 2 days ago.

Social/ personal history: she is married and they are staying happily together with her husband and their one kid. She graduated from college 3 years ago with a bachelors’ degree in business management. She runs a personal transport business. Her favorite foods are the locally prepared vegetables and sausages. She likes jogging every evening after work. She has one sex partner and has had two sex partners in her lifetime. She has never smoked but she reported taking alcohol when in college, but after marriage, she has never used alcohol.

Immunizations: pneumonia vaccine, January 2013; flu vaccine,e march 2014.

Family history

Grandparents are deceased with a fatal road accident.
Her mother is 47 with no medical problem

Her father deceased in a landslide

Her brother aged 18 is alive and with no medical problem

Her sister is 12 with no medical problem

Review systems:

General: she denies any chills or change in fever and no change in appetite

Skin: she denies skin rashes and skin dryness

HEENT: she denied ear pain, headache, dizziness, blurred vision and seeing spots

Neck: she denies neck pains and difficulty in moving the neck

Breast: she denies breast pain and nipple darkening.

Respiratory: she denies any wheezing and shortness of breath.

Gastrointestinal: she denies of any abdominal pain, constipation, and diarrhea.

Urinary: she reported pain when passing urine, and rated it as 5 in a scale of 1-10

 Endocrine: She denies any history of diabetes or thyroid disorders. No excessive thirst, polyuria, polydipsia and polyphagia.

OBJECTIVE DATA:

Vital signs: BP 115/77, T 92, P 60, and oxygen saturation on room air was 96%. Height 54 inches, weight 135 lbs. and BMI- 22.

General:  Topyster is a 25 year old Hispania woman who appears physically well. She is in good health and her hair is well groomed. She smiles appropriately and no odor in mouth or body noted. She speaks very fluent English, polite and well behaved.

SKIN: she has no skin rashes, lesions, nor dryness. In general, she has good skin turgor.

HEENT: the pupils are equal, round and very reactive to light and accommodation. Hair distribution is normal. Nares are patent, moist nose and good dental hygiene.

Breasts: the breasts were steady and no palpable nodes and no discharge noted.

Neck: no thyroid nodules or thyromegaly noted.

Chest/lungs: the chest is symmetrical and lungs are very clear and no wheezing.

Heart/ peripheral vascular: rhythm and arte are regular. No murmors or edema.

Genitals: pubic hair well distributed and her cervix is intact.

Musculoskeletal: presence of enough muscle tone and no edema noted. Good muscle tone and bulk is normal.

ASSESSMENT:

diagnosispositivesnegativesRationale & reference
Yeast infectionItching in the vaginal area and around the vulva. Burning sensation in the vaginal area Swelling of the vulva White/gray vaginal discharge Pain during sexual intercourseNo headaches No vomiting No fever No chillsMost yeast infections are caused by a type of yeast called candida albicanas (Dupont, et. al., 2009). The bacteria accumulate around the vagina resulting to the multiplicity of the yeast. The symptoms of the yeast infection include: itching in the vagina, burning sensation especially during urination and sexual intercourse, thick white discharge with cheese cottage appearance and swelling of the vulva (Mukherjee, Sheehan & Ghannoum, 2005).  These symptoms were confirmed in Topyster and it was made the primary diagnosis.  
Genital herpesBurning sensation during urinationNo fever No muscle aches No blister on the vagina No appetite lossIt is a sexually transmitted infection caused by the herpes simplex virus (Barton & Sen, 2007).  The general symptoms include fever, muscle aches in the back, buttocks and thighs. In women, blisters may be around the vagina, cervix or the anus. In men, blisters may be around the pennies, scrotum and around the anus. Pain during urination is common in both genders. (Wald, 2006) In the examination of Topyster, these symptoms were not confirmed and the patient did not complain of any of these.
endometriosisPain during urination and sexual intercourseNo abdominal pain or pelvic painEndometriosis is the abnormal growth of endometrial cells similar to those that form in the uterus. Its symptoms include painful periods, painful sex, pain in the lower abdomen and pelvic area (Ferrero, et. al, 2011). The patient confirmed pain during sex and urination.  
Lab testPatient resultsrationale
Urine culture (mid-stream)No ketones in urine Presence of protein, bilirubin, large nitrites and leucocyte esterase.Urinary tract infection is an infection that happens anywhere along the urinary tract. Its symptoms include a strong and urgent feeling if urination every time and burning sensation. The patient was advised to visit back the hospital if her symptoms worsened.
conditionpharmacologicaltestFollow uprationale
Yeast infectionNitrofuration in 100mg orally, twice daily for 7 days Diflucan 150mg one doseUrine test was positiveIf symptoms persist patient to visit the hospital after two weeksThe use of nitrofurationin the treatment of yeast prevents other additional infections that may result out of fungal infections.
     

Health promotion: the yeast infection is a fungal disease, which results out of bacterial infection (Mukherjee, Sheehan & Ghannoum, 2005). It is very important that the patient completes her medication even if she feele relieved. This will help prevent the development of other resistant microorganism. The patient is advised to forgo sexual intercourse until after her health has completely improved (Dupont, et. al., 2009). The patients should be advised to ask her husband to visit the hospital because he both has got the yeast infection.

Disease prevention: Pap smear should be performed according to the set standard procedures.  Testing should be carried out on the patient based on his medical history.

Reflection: I have learnt a lot from this study about yeast infection. From the study, it is very evident that observing cleanliness is the very best option of avoiding such medical complications. In order to avoid the yeast infection and other sexually transmitted diseases, it is very important that one observes cleanliness especially on their underpants. There is an urgent need to carry out public education about this sexually transmitted disease in order to avoid the spread of the disease and deal with the disease amicably. If we can carry out public education, then we can reduce the spread of the disease by a very high percentage.  Not all disease symptoms can be confirmed just by asking patient questions. Thorough examination of the patient is very necessary before commencing any treatment. Prescription of antibiotics in the patient’s medication is very necessary as it helps the patient fight against other additional diseases that may arise out of the bacteria that may attack the pubic parts (Soong & Einarson, 2009). Completion of the dose is very necessary as this will help prevent other medical complications that may result out of the same disease.

I feel much touched by the level at which the sexually transmitted diseases are attacking women. In fact, three quarters of the people who report to the hospital about sexually transmitted diseases are women. This shows that there is a very crucial need to help our young ladies in schools and those out of schools by educating them on hygiene best practices.

References

Barton, S. & Sen, P., 2007. Genital herpes and its management. BMJ. May 19, 2007; 334(7602):

 1048–1052. doi:  10.1136/bmj.39189.504306.55

Dupont, F, Lortholary, o.,Ostrosky-Zeichner3, L., et. al., (2009).Treatment of candidemia and

            invasive candidiasis in the intensive care unit: post hoc analysis of a randomized,

            controlled trial comparing micafungin and liposomal amphotericin B. Critical Care 2009,

 13 (5):R159 (doi:10.1186/cc8117)

Ferrero, S., Camerini, G., et. al (2011). Bowel endometriosis: Recent insights and unsolved

problems. World Journal of  Gastrointestinal Surgery . Mar 27, 2011; 3(3): 31–38. Published online Mar 27, 2011. 

Mukherjee, P., Sheehan, D.& Ghannoum, M., (2005). Combination Treatment of Invasive

            Fungal Infections. American Society for Microbiology: New York.

Soong, D. & Einarson, A., 2009. Vaginal yeast infections during pregnancy. Canadian Family

Physician. Mar 2009; 55(3): 255–256. College of Family Physicians of Canada.

Wald, A., 2006. Genital HSV‐1 infections. Sex transmission infection v. 82(3); 2006 June.

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