Nursing Assignment Help Sample for SOAP NOTE

Name:  KO

Date:  2/11/2024

Time:  8:30 Am

Age:  29

Sex: Female

SUBJECTIVE

CC: 

Vaginal itching and grey and light discharge 

HPI: 

KO, a 29-year-old Caucasian American female presents to the clinic and complains about vaginal itching. She further notes of grey and light vaginal discharge. Further notes that the discharge is malodorous and has a fishy smell after sexual intercourse. There is also a burning sensation during urination. 

Medications: No medication presently   

PMH

Allergies:  Patient denies

Medication Intolerances:  Patient denies

Chronic Illnesses/Major traumas:  No chronic condition or trauma

Hospitalizations/Surgeries

Patient denies

Family History

The patient is the only child. Mother has arthritis and high blood pressure. She is not aware of her father.  

Social History

KO works at a restaurant near her residence. She is also a part-time student pursuing a Bachelor’s degree in Human Resources Management. She is not married and has no child. She has a boyfriend of 2 years. She is heterosexual. She smokes and takes alcohol during weekends with her friends. She denies any illegal substance.

ROS

General

Denies fever, chills, weight change, and night sweats.

Cardiovascular

Denies palpitations, chest pain, edema, and PND 

Skin

Denies rashes, bleeding, discolourations, moles, or lesions.

Respiratory

Denies TB, coughing, dyspnea, pneumonia history, and hemoptysis  

Eyes

Denies corrective lenses, visual changes, and blurring

Gastrointestinal

Denies abdominal pain, constipation, eating disorders, ulcers, and black watery stools  

Ears

Denies hearing loss, ringing in the ears, discharge, and pain.

Genitourinary/Gynecological

Patient confirms vaginal itching related to grey and a light discharge. She notes a malodorous discharge and fishy vaginal smell after intercourse. She also has a burning sensation during urination. Denies pregnancy history. Last pap smear was a year ago.

Nose/Mouth/Throat

Denies nose bleeds, dysphagia, sinuses challenges and throat pain.  

Musculoskeletal

Denies back and joint pain. Denies history of fracture and joint swelling.

Breast

Denies bumps, lumps, and SBE.

Neurological

Denies seizures, weakness, blackout spells, and paresthesias

Heme/Lymph/Endo

Denies HIV negative according to her last examination three months ago. She denies bruising, history of blood transfusion, increased thirst, hunger, and heat intolerance.

Psychiatric

Denies anxiety, depression, sleeping challenges, suicidal ideation, and previous history.  

OBJECTIVE

Weight   159 lbs     BMI 25.7

Temp 97.8

BP  128/74

Height 5’5’’

Pulse 92

Resp 23

General Appearance

KO is a Caucasian female with high hygiene levels and oriented to the environment. She is friendly and shows no acute distress. She responds to questions appropriately.

Skin

Patient has normal and smooth skin. No colouration, acne or lesions. Skin is warm and dry.

HEENT

Head is normocephalic and no lesions. Hair is distributed evenly. Eyes: PEERLA. No lesions cataracts, or conjunctiva. Ears: Patent canals. Pearly grey TMs. Positive light reflex. Nose: Pink nasal mucosa. The neck is supple. ROM is fill and no masses or lesions. Oral mucosa is pink and moist. No sore throat, dental caries, or tooth break

Cardiovascular

Patient denies any cardiovascular challenge. S1, S2 have regular rate. No murmurs or grits. 2 seconds capillary refill. No edema.

Respiratory

Patient denies any respiratory challenge. The chest wall is symmetrical. Regular respirations and easy. Bilaterally auscultation. Clear lungs.

Gastrointestinal

No abdominal issue reported. Waist circumference normal and active BS in all quadrants. Non-tender and soft abdomen.  

Breast

No lumps, lesions, or masses in the two breasts. No skin discolouration. No discharge, wrinkling, or dimpling.

Genitourinary

Grey and light vaginal discharge with a fishy smell. Non-distended bladder. No CVA tenderness. Coarse pubic hair that is normally distributed. Consistent skin colour and pigmentation is general. No vulvar lesions noted. Pelvic examination shows light and grey malodourous discharge. Vaginal culture sent to the lab and pending results. Gravida 0, Para 0. Pink vaginal walls and no lesions. No tenderness nor masses. Non-palpable masses.

Appropriate rectal. No haemorrhoids evidence, bleeding, masses, or fissures.  

Musculoskeletal

Normal. ROM is full in all four extremities reflected in patient mobility

Neurological

Normal balance and gait, clear speech, good tone and erect posture.

Psychiatric

KO is oriented and alert. She is well groomed and demonstrates good hygiene levels. She maintains direct eye contact. Her speech is clear and soft. She responds appropriately to questions.

Lab Tests

Vaginal culture: Pending. Vaginal culture is used to evaluate the present micro-organisms in the vagina including their growth rate, patterns, and abnormalities. It is used to examine the balance of these micro-organisms including the aerobic and anaerobic (Nenadic & Pavlovic, 2015).

Wet mount test: Clue cells

pH: 5.2

Special Tests

None

Diagnosis

1.      Bacterial Vaginosis

The condition is described by bacteria overgrowth and vaginal inflammation. The condition can affect a woman at any age although frequent douching and unprotected sex enhance the risk. Common signs and symptoms include vaginal itching, burning sensation during itching, light and grey vaginal discharge that also has a fishy smell (Zozaya et al., 2016). The bacteria overgrowth is responsible for upsetting the balance especially with the rise of anaerobic ones. Min risk factors include Multiple sex partners, douching, and deficiency of lactobacilli bacteria. These symptoms are present in KO.

2.      Chlamydia

The condition falls in the Sexually Transmitted Diseases. It is caused by bacteria. It is difficult to treat the condition and if left unmanaged may result in serious health complications. Signs and symptoms begin a week or two after being exposed to the bacteria (Short, Gardner, Blum, Vaughn, & Rowan, 2015). Common signs and symptoms include pain during urination, vaginal discharge, painful intercourse, and low abdominal pain. It is caused by failure to use protection during intercourse, multiple sexual partners, and a history of STI. KO presents with these symptoms and has a history of UTI and yeast infections.

3.      Gonorrhoea

The condition is sexually transmitted and can infect both genders. Mostly affects the throat, rectum, and urethra. Common signs and symptoms include painful urination, vaginal discharge, pain during sexual intercourse, and Abdominal Pain. According to Papp, Schachter, Gaydos, and Van Der Pol (2014), the condition affects other body parts including rectum, throat, and eyes.

Primary Diagnosis

Bacterial Vaginosis: Condition results from natural bacteria imbalance. Condition considered primary diagnosis in KO based on her symptoms which include light and grey vaginal discharge, fishy smell in the discharge, burning sensation during urination, and painful intercourse (Zozaya et al., 2016). Besides, the pH is above 4.5, and wet mount test shows clue cells which confirm the condition.

Plan/Therapeutics

Plan: 

Further testing: None

Medication: Clotrimazole 50 mg applied twice at bedtime for one week.  Fluconazole PO daily.

Education: Education entails the condition and its prevention. KO further educated on the importance of taking the probiotics daily and adhering to the medication. The use of probiotics is a current and effective plan in managing lactobacilli dominance and depletion. Also included in the education plan is the importance of birth control and STI protection as KO does not use any. For promoting her overall health, KO should be educated on the effects of smoking and taking alcohol which, she should reduce. She should also be educated on the importance of yoghurt which is aimed at restoring bacterial balance.

Non-medication treatments: Yogurt which is used to restore balance in the vaginal bacteria. This is based on the lactobacillus bacteria present in the yoghurt.

 Follow-Up

KO to return to the clinic after two weeks for further checkup in case the symptoms do not reduce or become worse