Week 3 6551 Practicum SOAP Note

Week3 6551 Practicum: SOAP Note

Patientinitials: M. K Age: 28 years Gender: Female

SUBJECTIVEDATA

ChiefComplaint (CC): Thepatient is a twenty-eight years old Caucasian female who came to theclinic complaining of bad smelling vaginal discharge. She alsocomplains of itching and pain in the vagina.

Historyof the Present Illness (HPI): Thepatient has a history of COPD.

Medications:Currentlynot under any medication.

Allergies:NKDA

PastMedical History (PMH):Hospitalized with pneumonia two years ago.

PastSurgical History (PSH):No surgical history.

ImmunizationHistory:Tetanus in 2015.

SignificantFamily History:Mother diagnosed with breast cancer.

SocialHistory:The patient is a teacher. She does not smoke or drink.

CurrentMediation: Notunder any medication.

Reviewof the System: Regularlyexperience weight and appetite changes.

OBJECTIVEDATA

PhysicalExam:

VitalSigns:Weight: 178 Ibs Height: 5 Feet 7 inches BMI: 2Temp: 42oC BP: 110/67

Thepatient is alert, healthy-appearing, and responds appropriately.

HEET:Normalexternal appearance (Poliskyand Nichols, 2015)

CardiovascularCV:No murmurs, rubs, or gallops.

PulmonaryGI:No noticeable wheezes in the upper and lower pulmonary lobes.

GenitourinaryGU:No bladder tenderness or distension noted.

Integumentary:Normalskin color with no rashes or lesion.

Musculoskeletal:No muscle pain or leg cramps.

Neurological:Nosensation abnormalities.

ASSESSMENT

Basedon the above assessment, the differential diagnosis includesBacterial Vaginosis, Trachimoniasis, and Chlamydia. However, theprimary diagnosis of the patient is Bacterial Vaginosis, because thepatient possesses all its signs and symptoms. These includegreen-yellow vaginal discharge with a fishy smell, vaginal itchingand irritation, and discomfort during intercourse (Anzueto,2015).Trachimoniasis and Chlamydia are ruled out because the patient doesnot have painful urination and abdominal pains (InMechanick and In Kushner, 2016).

PLAN

Interventions:

  • The patient is advised to avoid using scented soaps, bubble baths, and vaginal deodorant.

Education:

  • Report to the clinic if the condition continues to deteriorate

  • .Limit the number of sex partners

  • Avoid using strong detergent to clean underwear

  • Avoid vaginal douching.

Prescription:

  • Metronidazole

  • Clindamycin

  • Tinidazole

  • Antibiotic gel

Therapies:LactobacillusColonization Therapy

ReflectionNotes:

Frommy practicum, I have learned the importance to have backgroundinformation on various diseases. InScholefield, In Sebti, and In Harris(2015), advocates for sufficient information when treating a patient.Therefore, when evaluating a similar patient in the future, I willensure I have sufficient information before handing and treating himor her.

References

Anzueto,A. (2015).&nbspERSMonograph Issue 69: Controversies in COPD.Sheffield, United Kingdom: European Respiratory Society.

InMechanick, J. I., &amp In Kushner, R. F. (2016).&nbspLifestylemedicine: A manual for clinical practice.

InScholefield, D., In Sebti, A., &amp In Harris, A.(2015).&nbspPharmacologycase studies for nurse prescribers.

Polisky,M. A., &amp Nichols, B. (2015).&nbspSOAPfor pediatrics.Malden, Mass: Blackwell Pub.