05 May Think about the details of the patients background, medical history, physical eval, labs and diagnostics, diagnosis, and treatment and management plan, and education strategie

PRAC 6552: Advanced Nurse Practice in Reproductive Health Care Practicum

Guidelines for a Comprehensive History and Physical SOAP Note

 

         Label each section of the SOAP note (each body part and system).

         Do  not use unnecessary words or complete sentences.

         Use standard abbreviations.

 

SUBJECTIVE DATA (S):  (information the patient/caregiver tells you)

 

Includes all of the information the patient tells you. Identifying data: Initials, age, race, gender, marital status. Name of informant, if not patient.

 

CHIEF COMPLAINT (CC): The reason for this health care visit. A statement describing the symptom(s), problem, condition, diagnosis, physician-recommended return, or other factors that are the reason for this patient visit (even if they bring no specific problem). If possible, use the patient’s own words in quotation marks.

 

HISTORY OF PRESENT ILLNESS (HPI): If the patient presents with specific problems, symptoms, or complaints, a chronological description of the development of the patient’s present illness from the first sign of each symptom to the current visit is recorded using the elements of  a symptom analysis. Those elements are:

· Location: Where it started, where it is located now

· Quality: Unique properties or characteristics of the symptom

· Severity: Intensity, quantity, or impact on life activities; duration: length of episode

· Timing: When symptom started, frequency (patient’s “story” of the symptom), context (under what conditions it occurs)

· Setting: Under what conditions the symptoms occur, activities that produce the symptoms

· Alleviating and aggravating factors: What makes it better and/or worse, what meds have been taken to relieve symptoms, did the meds help or not, does food make symptoms worse or better

· Associated signs and symptoms: Presence or absence of other symptoms or problems occurring with their complaint; include pertinent negatives and information from the patient's charts (e.g., lab data or previous visit information) 

 

In the case of a  well visit, describe the patient's usual health and summarize health maintenance needs and activities.

 

PAST MEDICAL HISTORY (PMH):

· Allergies

· Current medications: prescription and over the counter

· Age/health status

· Appropriate immunization status

· Previous screening tests result

· Dates of illnesses during childhood (may not be very important in adults; exceptions may include rheumatic fever or chronic illnesses continuing into adulthood)

· Major adult illnesses (include history of diabetes, hypertension, gastrointestinal diseases, pulmonary disease, cardiovascular disease, cancer, tuberculosis, sexually transmitted infections (STIs), HIV/AIDS, gynecological or urological problems, drug and/or alcohol abuse, and psychiatric illness)

· Injuries

· Hospitalizations (reason, hospital, attending physician [if known])

· Surgeries (include hospital and year)

 

FAMILY HISTORY (FH): Age and current health status or age at death and cause of death of each family member (parents, siblings, and children) is recorded. Occurrence within the family of illnesses of an environmental, genetic, or familial nature are recorded in family history. Ask about the presence in the family of any of the following conditions: asthma, glaucoma, myocardial infarctions, heart failure, hypertension, cancer, tuberculosis, diabetes, kidney disease, hemophilia, sickle cell trait or disease, psychiatric diseases, alcoholism allergies, family violence, mental retardation, epilepsy, and congenital abnormalities.

Record any specific diseases related to problems identified in CC, HPI, or review of symptoms (ROS).  SOCIAL HISTORY (SH): Record important life events: marital status, occupational history, military service, level of education. Record lifestyle and current health habits (may be here or in ROS): exercise, diet, safety (smoke alarms, seatbelts, firearms, sports), living arrangements, hobbies, travel. Record religious preference relevant to health, illness, or treatment. Record habits: use of drugs, alcohol, and tobacco.

Resources: resources to pay for care, insurance, worries about cost of care, history of postponing care.

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.

 

REVIEW OF SYSTEMS (ROS): There are 14 systems for review. Record a summary for each system.  Unexpected or positive findings need complete symptom analysis.

 

1) Constitutional symptoms : Overall health, weight gain or loss, ideal weight, fever, fatigue, repeated infections, ability to carry out activities of daily living.

2) Eyes : eye care, poor eyesight, double or blurred vision, use of corrective lenses or medications, redness, excessive tearing, pain, trauma, date and results of last vision screening or eye exam

3) Ears, nose, mouth, and throat : Ears: hearing acuity, exposure to high noise level, tinnitus, and presence of infection or pain, vertigo, use of assistive hearing device. Nose: sense of smell, discharge, obstruction, epistaxis, sinus trouble. Mouth and teeth: use of oral tobacco or smoking cigarettes, last dental exam date and result, pattern of brushing and use of dental floss and fluoride toothpaste, dentures, bleeding of gums, sense of taste, mouth odor or ulcers, sore tongue. Throat: sore throat, hoarseness, dysphagia.

4) Cardiovascular : Exercise pattern to maintain cardiovascular health. History of abnormal heart sounds (including murmur), chest pains, palpitations, dyspnea, activity intolerance, usual blood pressure, ECG (date, reason), cholesterol level (date), edema, claudication, varicose veins.

5) Respiratory : Exposure to passive smoke. History of respiratory infections, usual self-treatment, cough, last chest x-ray (date, result), exposure to tuberculosis (TB) and last TB skin test (date and result), difficult breathing, wheezing, hemoptysis, sputum production (character, amount), night sweats.

6) Gastrointestinal : Dietary pattern, fiber and fat in diet, use of nutritional supplements (vitamins, herbs), heartburn, epigastric pain, abdominal pain, nausea and vomiting, food intolerance, flatulence, diarrhea, constipation, usual bowel pattern, change in stools, hemorrhoids, jaundice.

7) Genitourinary : Nocturia, dysuria, incontinence, sexual practices, sexual difficulty, venereal disease, history of stones. Men: slow stream, penile discharge, contraceptive use, self-testicular exam. Women: onset, regularity, dysmenorrhea, intermenstrual discharge or bleeding, pregnancy history (number, miscarriages, abortions, duration of pregnancy, type of delivery, complications), menopause (if present, use of hormone replacement therapy), last menstrual period (LMP), contraceptive use, last pap smear (date and result), intake of folic acid.

8) Musculoskeletal : Exercise pattern, use of seatbelts, use of safety equipment with sports, neck pain or stiffness, joint pain or swelling, incapacitating back pain, paralysis, deformities, changes in range of motion of activity, screening for osteoporosis, knowledge of back injury/pain prevention.

9) Integumentary (skin and/or breast): Use of skin protection with sun exposure, self-examination practices in assessing skin, general skin condition and care, changes in skin, rash, itching, nail deformity, hair loss, moles, open areas, bruising. Breast: practice of self-breast exam, lumps, pain, discharge, dimpling, last mammogram (date and result).

10) Neurologic : Muscle weakness, syncope, stroke, seizures, paresthesia, involuntary movements or tremors, loss of memory, severe headaches.

11) Psychiatric : Nightmares, mood changes, depression, anxiety, nervousness, insomnia, suicidal thoughts, potential for exposure to violence.

12) Endocrine : Thyroid problems, cold or heat intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair or nail texture, unexplained weight change, changes in facial or body hair, change in hat or glove size, use of hormonal therapy.

13) Hematologic/lymphatic : Bruising, unusual bleeding, fatigue, history of anemia, last HCT and result, history of blood transfusions, swollen and/or tender glands.

14) Allergic/immunologic :   Seasonal allergies, previous allergy testing, potential for exposure to blood and body fluids, immunized for hepatitis B, immunosuppression in self or family member, use of steroids.

 

OBJECTIVE DATA:  A concise report of physical exam findings. Systems (there are 12 systems for examination):

   

1. Constitutional (VS: Temp, BP, pulse, height and weight); a statement describing the patient’s general appearance

2. Eyes

3. Ear, nose, throat

4. Cardiovascular 

5. Respiratory

6. Gastrointestinal 

7. Genitourinary

8. Musculoskeletal

9. Integument/lymphatic pertaining to each location

10. Neurologic

11. Psychiatric

12. Hematologic/immunologic   

Results of any diagnostic testing available during patient visit.

 

ASSESSMENT (A):

· List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.

· Diagnosis must be codable (CPT codes).

· Provide adequate information to justify ordering additional data (e.g., lab, x-ray).

· Do not write that a diagnosis is to be “ruled out.” State the working definitions (symptoms, probable diagnoses) of patient problems in the following areas:

· Health maintenance

· Acute self-limited problems 

· Chronic health problems 

In cases where the diagnosis is  already established, indicate whether the diagnosis has the following characteristics: improved, well controlled, resolving, resolved, inadequately controlled, worsening or failing to change as expected.

Note: Inadequately controlled chronic conditions should have a possible etiology written (e.g., exacerbation, progression, side effects of treatment) if known.

 

 

PLAN (P): (The plan should be discussed with and agreed on by the patient.)

 

The treatment plan includes a wide range of management actions:

· Laboratory test

· Consultation requested and justification

· Medications prescribed (name, dose, route, amount, refills) 

· Appliances prescribed

· Lifestyle modifications: diet, activity modification

· Patient education and patient responsibilities (e.g., keeping food diary or BP record)

· Patient counseling related to lab/diagnostic results, impression, or recommendations

· Family education

· Details concerning coordination of care: arranging and organizing patient's care with other providers and agencies

· Follow-up should be specified with time (in days, weeks, months) and/or circumstances of return or noted as PRN

 

 

Note: Number the plan to correlate with the problem list in the Assessment.

© 2022 Walden University, LLC

,

Alexis Tuero

Miami Regional University

Date of Encounter: 9/8/21

Preceptor/Clinical Site: Taymi Rodriguez

Clinical Instructor: Emelio Garcia

Soap Note # 1 Vulvovaginal Candidiasis

PATIENT INFORMATION

Name: DC

Age: 40 years

Gender at Birth: Female

Gender Identity: Woman

Source: DC

Allergies: Reports of no known food or drug allergies.

Current Medications: Metformin

PMH: She reports that she is a known diabetic. She reports of a history of hospitalizations ten years ago after she was diagnosed with the condition. She reports that she was diagnosed with diabetes type 2 and it was medically controlled.

Immunizations: Reports of updated immunizations according to schedule.

Preventive Care: She reports that she has been exercising and feeding on a diabetic diet to control the glycemic levels. She also reports that she has been attending all appointments and adhering to the medications. She also reports that she has been following the COVID-19 prevention protocol.

Surgical History: She reports of a history of tubal ligation.

Family History: She reports that she is a mother to two children who are healthy and well. She also reports that her mother died of diabetic ketoacidosis and father died of a stroke.

Social History: she reports that she is a university graduate. She works as a secretary in the Miami state office. She also reports that she has been married for 12 years, blessed with two children and lives with her husband. She reports that she was an alcoholic but she has quit. She denies of cigarette smoking or abuse of drug substances.

Sexual Orientation: Heterosexual, she is married and lives with her husband.

Nutrition History: she reports that she feeds on a highly nutritious balanced diet that contains plenty vegetables and fruits. She also reports that she avoids foods that are high in cholesterol, soft drinks and foods that she was advised against eating.

Subjective Data:

Chief Complaint: “I have a thick white vaginal discharge and vaginal soreness”

Symptom analysis/HPI:

DC is a 40-year-old female who presents to the physician’s office with chief complains of whitish discharge from the vagina. She reports that the discharge is thick and is odor-free and that it started about three days ago. She reports that the discharge was initially watery but it changed into whitish and became thick. She also reports that she has been experiencing vaginal soreness and experiencing pain during sexual intercourse. She also reports that she has been experiencing a burning sensation during urination. She reports that two weeks ago she experienced urinary tract infection symptoms and took cephalexin to treat the UTI. She also reports that she is a known diabetic.

Review of Systems (ROS)

CONSTITUTIONAL: She denies of unintended weight loss, fever, night sweats and increased fatigue.

NEUROLOGIC: She denies of seizures, paralysis or syncope.

HEENT: Head: she denies of past head traumas or skull fractures, denies also of sudden severe headaches. Eyes: she denies of blurred vision, double vision or eye pain. Ears: she denies of tinnitus, reduced sense or difficulty in hearing. Nose: She denies of nose bleeding, nasal lesions, a runny nose or nasal congestion. Throat: She denies of throat pain or soreness.

RESPIRATORY: She denies of shortness of breath or coughing.

CARDIOVASCULAR: She denies of any known cardiovascular diseases. she also denies of experiencing chest pains.

GASTROINTESTINAL: DC also reports that she is feeding as usual. Denies of any eating abnormalities.

GENITOURINARY: DC reports of a burning sensation during urination. She denies of a persistent urge to urinate, increased urine frequency, changes in urine color or strong-smelling urine.

MUSCULOSKELETAL: she denies of muscle pain, joint pains or stiffness and a decrease in range of motion.

SKIN: she denies of any open wounds, skin discolorations or development of rashes.

Objective Data:

VITAL SIGNS: Temp; 37.1 C BP; 119/78 P; 88 Resp; 21 rpm

GENERAL APPREARANCE: DC is alert and well-oriented. She is of good hygiene and is well dressed. She is not in acute distress.

NEUROLOGIC: cranial nerves are fully functioning.

HEENT: Head- normocephalic and free of lumps or masses, no skull fractures noted, hair is blonde in color. Eyes- PERRLA. Extraocular muscles are intact, no pallor or jaundice noted.

Ears: Patent ear canals, good sense of hearing bilaterally, tympanic membrane is gray in color and not inflamed. Nose: patent nostrils with no lesions, septum is present and is centrally located. No abnormalities noted. Neck: has a full range of motion with thyroid glands and cervical lymph nodes not enlarged. Jugular veins are not distended.

CARDIOVASCULAR: S1 and S2 are present with no extra sounds. Moreover, no murmurs or rubs heard on auscultation. Capillary refill of two seconds and she is free of edema.

RESPIRATORY: Regular breathing pattern and rate, easy respirations. Symmetrical chest wall, with no fluid consolidation or adventitious sounds.

GASTROINTESTINAL: bowel sounds are present in all the four quadrants. The abdomen is soft and non-tender with no hernias or hepatosplenomegaly.

Genitourinary: On inspection, the vulva is swollen and has reddened. A thick whitish discharge from the vaginal opening also noted. On speculum examination, presence of a thick whitish discharge from the vagina, vaginal wells are rugate with no tumors, lesions, the cervix is soft and intact, the uterus is free of tumors or uterine fibroids.

MUSKULOSKELETAL: Full range of motion of all the extremities.

INTEGUMENTARY: The skin is warm and intact with some black discolorations in the lower and upper extremities.

ASSESSMENT: DC is a 40-year-old client who presents to the healthcare organization with chief complains of thick whitish vaginal discharge, vaginal soreness, pain during sexual intercourse and a burning sensation during urination. She reports of a history of urinary tract infection two weeks ago and she took an antibiotic. She is also a known diabetic patient. This has predisposed her to vulvovaginal candidiasis since the normal flora has been disturbed with intake of antibiotics. On physical examination, the skin has some black discolorations, the vulva has swollen and reddened.

Main Diagnosis

Vaginal Candidiasis (B 37.3): Of essence to the diagnosis is the pertinent positives of the condition, for instance, whitish vaginal discharge that is thick, pain during sexual intercourse, vaginal soreness and irritation and a burning sensation during urination. Furthermore, the client is predisposed to the condition since she is diabetic and has a history of intake of antibiotics about two weeks ago. Some of the risk factors of vulvovaginal candidiasis include being diabetic, use of certain contraceptives, low estrogen levels and having a compromised immune system (Willems et al., 2020).

Differential diagnosis

Urinary Tract Infections (UTI) (N390): of essence to the diagnosis is a burning sensation during urination and watery vaginal discharge. Pertinent negatives of the condition include urine frequency and urgency, strong-smelling urine and change of urine color, fever, pelvic or lower-abdominal pain (Anger et al., 2019).

– Trichomoniasis (A5900): of essence to the diagnosis is vaginal itching and soreness, vaginal discharge and a swollen vulva. Trichomoniasis mostly presents with pain in the abdomen, pain during sexual intercourse or urination, vaginal discharge that is foul-smelling, inflammation of the cervix and vulva (Kissinger et al., 2021).

– Bacterial Vaginosis (N760): It is a type of vaginal inflammation that is caused by the overgrowth of bacteria that naturally resides in the vagina. Some of the symptoms of the condition include vaginal itching, a burning sensation during urination, foul-smelling “fishy” vaginal odor and vaginal discharge that may be thin, gray, white or green (Redelinghuys et al., 2020). Of essence to the diagnosis is whitish vaginal discharge, a burning sensation during urination and vaginal itching.

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

· – CBC: pending

· Urinalysis: pending

· Urine cultures: pending

· Vaginal discharge cultures: pending

· Pregnancy tests; negative

· RBS: 10.3 mmol/dl

Pharmacological treatment:

Clotrimazole pessaries 100mg OD for 6 days (Mendling et al., 2020).

Non-Pharmacologic treatment: To prevent unnecessary intake of antibiotics (Shukla & Sobel, 2019).

Education

Educate the client about the diagnosis and educate her on her to apply the medication, for instance, to use an applicant to apply the medication mostly when she is lying down. Educate her also on prevention strategies of the condition, for instance, to avoid unnecessary intake of antibiotics unless prescribed. Educate the patient also on the benefits of completing the dosage. Some of the other prevention strategies that the client needs to be enlightened on is perianal hygiene, to wear breathable under wears, to avoid wet clothing and contraceptives that lower estrogen levels (Belayneh et al., 2017).

Follow-ups/Referrals

To return after six days for further tests. To make a follow-up of the lab results.

References

Anger, J., Lee, U., Ackerman, A. L., Chou, R., Chughtai, B., Clemens, J. Q., … & Chai, T. C. (2019). Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline.  The Journal of urology,  202(2), 282-289.

Belayneh, M., Sehn, E., & Korownyk, C. (2017). Recurrent vulvovaginal candidiasis.  Canadian Family Physician,  63(6), 455-455.

Kissinger, P. J., Gerwen, O. T. V., & Muzny, C. A. (2021). Trichomoniasis. In  Neglected Tropical Diseases-North America (pp. 131-155). Springer, Cham.

Mendling, W., Atef El Shazly, M., & Zhang, L. (2020). Clotrimazole for vulvovaginal Candidosis: more than 45 years of clinical experience.  Pharmaceuticals,  13(10), 274.

Redelinghuys, M. J., Geldenhuys, J., Jung, H., & Kock, M. M. (2020). Bacterial vaginosis: current diagnostic avenues and future opportunities.  Frontiers in cellular and infection microbiology,  10, 354.

Shukla, A., & Sobel, J. D. (2019). Vulvovaginitis caused by Candida species following antibiotic exposure.  Current infectious disease reports,  21(11), 1-6.

Willems, H. M., Ahmed, S. S., Liu, J., Xu, Z., & Peters, B. M. (2020). Vulvovaginal candidiasis: a current understanding and burning questions.  Journal of Fungi,  6(1), 27.