Posted: December 6th, 2022

NUR 514 Comprehensive Womens Health history Soap note

NUR 514 Comprehensive Womens Health history Soap note

Comprehensive Women’s Health History and Physical Template

Encounter date: 01/11/2021

Patient Initials: O.R. Gender:    Female   Age:   39 years            Race/Ethnicity: Haitian American

Reason for Seeking Health Care: The chief complaint is stated by the patient as “I have noted some discharge on my underwear.”

History of Present Illness (HPI): The patient is a 39 year-old Haitian American female who presents with vaginal discharge to the clinic. She accepts a previous history of vaginal discharge on a number of occasions. The current discharge was noted by the patient three days before the visit NUR 514 Comprehensive Womens Health history Soap note . The location is the genitalia and specifically the vulva which remains wet with the discharge and stains the underwear. The discharge is constantly there since it was noted and is therefore not intermittent. It is characteristically fowl-smelling and yellowish-brown in color. The discharge is increased or aggravated by activity done while standing, but reduced or relieved by lying supine. The timing of the discharge is all day. The patient rates the severity of the symptoms at 6/10 NUR 514 Comprehensive Womens Health history Soap note .

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Allergies (Drug/Food/Latex/Environmental/Herbal): The patient denies any allergies.

Current Perception of Health: Her current perception of health is absence of disease and so she currently feels unhealthy and sick.

Current Medications (including over the counter): She is currently not taking any medications, including OTC drugs.

Menstrual History

Age at Menarche: 12 years old.

Last menstrual period: 27/10/2021

Menstrual Pattern: Regular

Cycle Length: 28 days.

Duration of Flow: Four (4) days.

Amount of Flow: Heavy.

Bleeding Pattern: Continuous.

Break through Bleeding: Occasional but not regularly.

Gynecologic History

History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable): The patient denies any history of breast disease in her or even her family NUR 514 Comprehensive Womens Health history Soap note . She is a mother of two and breastfed both of her children up to the age of two years. The first six months were for exclusive breastfeeding. She regularly does to herself breast self examination as she was taught years ago. Her last mammogram was done five years ago in 2016 and no masses were detected.

Previous GYN surgery (may include that in surgical history): She has no history of gynecological surgery.

History of infertility: She denies any history of infertility.

History of diethylstilbestrol (DES) use by patient’s mother: Negative for use of DES by the patient’s mother.

Last Pap smear, history of abnormal pap: The last Pap smear was three years ago in 2018, done together with the human papillomavirus or HPV test. She has had no history of abnormal Pap smear results.

Pre-menopause/menopause

Vasomotor symptoms: She denies any pre-menopause vasomotor symptoms such as hot flushes.

Hormone Replacement Therapy: She denies any history of hormonal replacement therapy.

Sexual and Contraceptive History

Current method of contraception: Intrauterine contraceptive device (IUCD).

Sexually active: She is positive about sexual activity.

Number of sexual partners: Three (3).

New partners in the 3-6 months: Yes, two.

Condom use: Sometimes, not consistently.

History of sexual abuse: She admits to having been sexually abused as a minor aged just ten years by a person known to her.

History of sexually transmitted infections (STIs): She has been treated before for chlamydia and lymphogranuloma venereum.

Obstetric History (including complications): She is a para 2 gravida 2 with two surviving children. Throughout her obstetric history she has never had a miscarriage. Both children were born at term with good Apgar scores and none was underweight or overweight.

Past Medical History (PMH): The patient has a history of gestational diabetes mellitus that was treated and resolved. She is currently in impaired glucose tolerance or prediabetic phase with a random blood sugar range of 150 mg/dL to 188 mg/dL. She suffers no other chronic conditions. She has never been admitted to the hospital as an inpatient. NUR 514 Comprehensive Womens Health history Soap note .

Major/Chronic Illnesses: None.

Trauma/Injury: None.

Hospitalizations: None.

Past Surgical History: The patient presents no notable surgical history.

Family Medical History: She reports that the mother is diabetic (type II) and the father has hypertension. There is also a history of overweight and obesity on the paternal side.

Social History

Living condition: She lives in a suburban community that is poor and lacks the basic commodities of everyday life. She however works as a housekeeper in a hotel and earns enough to guarantee her upkeep. Both her children are grown and no longer depend on her. Her children live within the same locality and regularly visit her.

Marital status: She has never been married but got her two children from two different fathers from her past relationships.

Education: She dropped out in high school when she got pregnant with her first child.

Employment: She currently works as a housekeeper in a local hotel. NUR 514 Comprehensive Womens Health history Soap note

Occupation: Housekeeper.

Social supports: She has a strong social support system in the form of her children and parents who also live within the same state.

Habits (smoking, alcohol use and illicit drugs use): She was a smoker of a pack a day up to two years ago when she stopped on the advice of a physician. She still drinks alcohol socially over the weekends when with friends.

Health Maintenance

Age-appropriate health promotion/maintenance and screening history: She has received health promotion and education as an antenatal mother. She has also received breast self examination education in the well woman clinic. After every three years, she goes for cervical cancer screening by way of a Pap smear and HPV test.

Immunization history: She received all the childhood immunizations as a child under five years. She has also received a booster Tdp, Pneumovax, and recently two doses of Pfizer BioNTech Covid-19 vaccine.

Review of Systems (ROS)

General: Denies fatigue, malaise, weight loss, fever, or chills.

Dermatology: Denies rashes, eczema, or itching.

HEENT: Negative for headaches, diplopia, photophobia, otorrhea, tinnitus, sneezing, rhinorrhea, or sore throat.

Neck: Negative for cervical lymphadenopathy r jugular distension.

Pulmonary System: Denies dyspnea, coughing, or chest indrawing.

Cardiovascular System (CVS): Denies palpitations, chest tightness, or pain in the chest.

Breast: Denies any lumps or masses on breast self examination. NUR 514 Comprehensive Womens Health history Soap note

Gastrointestinal (GI) System: Negative for abnormal bowel movements. She also denies diarrhea, vomiting, or nausea.

Genitourinary (GU) System: Denies painful micturition but reports vaginal discharge.

Female Genitalia: Denies visible lesions on the vulva, but reports fowl-smelling vaginal discharge.

Musculoskeletal System: Denies myalgia or arthralgia/ joint pains.

Neurological System: She is negative for syncope, paraesthesia, paresis, or paralysis.

Endocrine: Denies polydipsia, polyphagia, or heat/ cold intolerance. Also denies hormonal therapy.

Psychologic: Negative for hallucinations, delusions, or suicidality.

Hematologic/Lymphatic: Denies lymphadenopathy or a history of splenectomy (Bickley, 2017).

Physical Examination

Vital Signs

Blood Pressure (BP): 120/85 mmHg;   Temperature: 98.8°F;        Heart Rate (HR): 78 b/m   Respiratory Rate (RR): 17 breaths/ minute.

Height: 167.6 cm   Weight : 100 kg   Body Mass Index (BMI): 35.6 kg/m²    Pain: 0

General Appearance: The patient is well-groomed with clothes that are appropriate for the time of the day and the weather.

Dermatology: No rashes detected or any lesions suggestive of skin cancer (basal cell carcinoma).

HEENT: Normocephalic. PERRLA, EOMI. Throat not erythematous.

Neck: No lymph nodes enlarged.

Pulmonary System: Scattered crackles in otherwise clear lung fields. No chest indrawing.

Cardiovascular System (CVS): S1 and S2 audible with rate and rhythm regular (RRR).

Breast: No lumps detected on breast examination. NUR 514 Comprehensive Womens Health history Soap note

Gastrointestinal (GI) System: Bowel sounds present. No guarding.

Genitourinary (GU) System: No lesions found on the vulva. Presence of a yellowish-brown discharge.

Female Genitalia: No external lesions. Positive for a yellowish-brown fowl-smelling discharge.

Musculoskeletal System: Full range of movements with no joint stiffness. Patellar reflex intact.

Neurological System: She is alert and oriented in space, time, person, and event.

Endocrine: No signs of hypothyroidism found.

Psychologic: A normal mental status examination (MSE).

Hematologic/Lymphatic: Spleen is present and palpable.

Significant Data/Contributing Dx/Labs/Misc ·       Fowl-smelling discharge ·       CRP 3 mg/dL ·       ESR 30 mm/hr ·       WBC 12.5 x 109/L

Assessment

Differential Diagnoses (3 minimum):

1. Trichomoniasis: A protozoan causes trichomoniasis. The condition is typically transferred through sexual intercourse, but it can also be obtained through the sharing of towels or swimwear. It produces a foul-smelling green or yellow discharge. Inflammation and itching are also frequent complaints, while some patients may not have any (Hammer & McPhee, 2018; Jameson et al., 2018; Huether & McCance, 2017).
2. Bacterial vaginosis: Bacterial vaginosis is a bacterial infection of the cervix. It is the most frequent cause of abnormal vaginal discharge in reproductive-age females. In some ladies, the illness generates a “fishy” smell and vaginal discomfort. Others may have no complaints at all (Hammer & McPhee, 2018; Jameson et al., 2018; Huether & McCance, 2017).
3. Chlamydia/ Gonorrhea: Sexually transmitted diseases (STIs) such as gonorrhea and chlamydia can cause abnormal vaginal discharge. It is frequently yellow, greenish, or hazy in appearance (Hammer & McPhee, 2018; Jameson et al., 2018; Huether & McCance, 2017) NUR 514 Comprehensive Womens Health history Soap note .

Primary Diagnoses: Trichomoniasis or bacterial vaginosis.

Plan (For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit):

Diagnoses: Trichomoniasis.

Laboratory/Diagnostic Studies: CRP (3 mg/dL), ESR (30 mm/hr), WBC (12.5 x 10⁹/L), microscopy (positive for Trichomonas vaginalis).

Therapeutic (Non-pharmacological interventions): Use of pomegranate extract or apple cider vinegar to kill off the parasite (Nall, 2019).

Pharmacological Therapy: Metronidazole (Flagyl) 400 mg b.d. x 7 days. NUR 514 Comprehensive Womens Health history Soap note

Patient Education/Anticipatory Guidance: Consistent use of condoms during intercourse if cannot be faithful to one sexual partner and counseling for HIV testing.

Referrals: To counselor for HIV testing.

Follow up: After one week to review effectiveness of the treatment.

DEA#:  101xx010101                          STU Clinic                                   LIC# 100xx                                         

Tel: (000) xx4                                                                             FAX: (000) 5xxx2

Patient Name: (Initials) __Miss O.R. ___       Age ___39 Years Old__

Date: __10.11.2021__

RX _ Metronidazole (Flagyl) 400 mg twice daily x 7 days._

SIG:

Dispense:  ___________                                                     Refill: _________________

       No Substitution

Signature: ____________________________________________________________

 

 

Signature (with appropriate credentials): __________________________________________

 

References

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12^th ed. Wolters Kluwer.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6^th ed. Elsevier, Inc.

Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds) (2018). Harrison’s principles of internal medicine, 20^th ed. McGraw-Hill Education. NUR 514 Comprehensive Womens Health history Soap note

Nall, R. (June 24, 2019). Is it possible to treat trichomoniasis at home? https://www.healthline.com/health/home-treatments-for-trichomoniasis#popular-treatments

 

 

Comprehensive Women’s Health History and Physical Template

  

Encounter date:

 

Patient Initials:                     Gender:                      Age:                Race/Ethnicity:

 

Reason for Seeking Health Care

 

History of Present Illness (HPI)

 

Allergies (Drug/Food/Latex/Environmental/Herbal)

 

Current Perception of Health

 

Current Medications (including over the counter)

 

Menstrual History

Age at Menarche

Last menstrual period

Menstrual Pattern

Cycle Length

Duration of Flow

Amount of Flow

Bleeding Pattern

Break through Bleeding

 

Gynecologic History

History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable)

Previous GYN surgery (may include that in surgical history)

History of infertility NUR 514 Comprehensive Womens Health history Soap note

History of diethylstilbestrol (DES) use by patient’s mother

Last pap smear, history of abnormal pap

 

Pre-menopause/menopause

Vasomotor symptoms

Hormone Replacement Therapy

 

Sexual and Contraceptive History

Current method of contraception

Sexually active

Number of sexual partners

New partners in the 3-6 months

Condom use

History of sexual abuse

History of sexually transmitted infections (STIs)

 

Obstetric History (including complications)

 

Past Medical History (PMH)

Major/Chronic Illnesses

Trauma/Injury

Hospitalizations

 

Past Surgical History

 

Family Medical History

 

Social History

Living condition

Marital status

Education

Employment

Occupation

Social supports

Habits (smoking, alcohol use and illicit drugs use)

 

Health Maintenance

Age-appropriate health promotion/maintenance and screening history

Immunization history

 

Review of Systems (ROS)

General

Dermatology

HEENT

Neck

Pulmonary System

Cardiovascular System (CVS)

Breast

Gastrointestinal (GI) System

Genitourinary (GU) System

Female Genitalia

Musculoskeletal System

Neurological System.

Endocrine

Psychologic

Hematologic/Lymphatic

 

Physical Examination

 

Vital Signs

Blood Pressure (BP:           Temperature                Heart Rate (HR)        Respiratory Rate (RR)

Height                    Weight            Body Mass Index (BMI)                Pain

 

General Appearance

Dermatology

HEENT

Neck

Pulmonary System

Cardiovascular System (CVS)

Breast

Gastrointestinal (GI) System

Genitourinary (GU) System

Female Genitalia

Musculoskeletal System

Neurological System.

Endocrine

Psychologic

Hematologic/Lymphatic

 

Significant Data/Contributing Dx/Labs/Misc

 

Assessment

Differential Diagnoses (3 minimum)

Primary Diagnoses

 

Plan (For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit)

Diagnoses

Laboratory/Diagnostic Studies

Therapeutic (Non-pharmacological interventions)

Pharmacological Therapy

Patient Education/Anticipatory Guidance

Referrals

Follow up

 

DEA#:  101xxx                      STU Clinic                                   LIC# 100xx                                               

Tel: (000) 5xx-123xx                                                                            FAX: (000) x5-12xx

Patient Name: (Initials)______________________________        Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense:  ___________                                                     Refill: _________________

       No Substitution

Signature: ____________________________________________________________

 

 

 

Signature (with appropriate credentials): __________________________________________

 

References (must use current evidence-based guidelines used to guide the care [Mandatory]) NUR 514 Comprehensive Womens Health history Soap note