Download N589 Virtual patient SOAP and more Assignments Nursing in PDF only on Docsity!
Date: 8/27/
Time: 0900 a.m.
Patient: XXX
DOB: XX/XX/
PCP: None/Changed this visit to Me-Morgan Longtin-FNP
Subjective:
CC : “Vaginal itching & drainage”
HPI : XXX is a 52-year-old female presenting to the clinic today for vaginal itching and drainage. These
symptoms started roughly 4 days ago and have continued to get worse, becoming most notably worse over the last 24 hours. Her vaginal drainage is white and thick denying any bleeding, purulent drainage, and odor. Urination seems to aggravate her vaginal itching, with some discomfort upon initiating stream but no dysuria. She has been using Vagisil OTC that seemed to somewhat improve her symptoms. Denies any nausea, vomiting, abdominal or pelvic pain, vaginal bleeding, dysuria, hematuria, fevers/chills, and concern for any STIs. She is currently sexually active with the same partner for the last 27 years, her husband, though due to her current symptoms has not been for the last two weeks. She was seen for this chief complaint sometime last year for which she was successfully treated with a one-time dose of Fluconazole. Also, during this visit, she was also put on metformin and diagnosed with pre-diabetes. XXX is new to the area and has not yet established with a PCP. Mentioned the desire to get caught up on her health maintenance during this visit, as well as make me her PCP. She does report increased stress and time-constraints relating to the move contributed to the 20 pound weight gain she experienced over the last year. Annual wellness visit components discussed and listed below. All history components discussed and updated this visit- also listed below.
ROS
Constitutional- Denies any fatigue, fever, and chills. Does report a 20 pound weight gain over the last year. Abdominal/Gastrointestinal: Denies any abdominal pain, nausea, vomiting, or bowel disturbances. Genitourinary: Denies dysuria, hematuria, vaginal bleeding, pelvic pain, … Positive for vaginal itching, irritation, and drainage-white and thick in nature. LMP 2 months ago (irregular) and is sexually active. Neurologic/Mental Health: Denies any headaches, dizziness, and mental health concerns. Does report increased stress over the last year during her move to this area, however, does now feel things are finally stable at home and work and stress is significantly improved.
Medical History:
- Pre-Diabetes-Diagnosed 2022. Currently treated with lifestyle, diet, and physical activity interventions and 500 mg of metformin daily. Not checking BG levels at home.
**Not well-controlled
- Essential Hypertension- Date of diagnosis not known. Currently treated with lifestyle interventions and lisinopril 5 mg daily. Checks BP at home occasionally- been in 130s for SBP. **Not well-controlled Surgical History: 1) C-Section in 20XX Reproductive History: -She is a Gravida-1, Para- -Patient has irregular periods roughly every 2 months that are starting to be less frequent and lighter in nature. Mild-moderate menstrual flow. -LMP was roughly 2 months ago. -History of gyn procedures: C-section X In a sexual relationship? partner(s)?: Yes, 1 male partner for 27 years-her husband Contraception: Husband has had a vasectomy Desire/need for STD Screenings: N/A 1 time Hep C screen: Unknown. ***Will discuss with patient next FO visit. Hospitalizations:
- Delivery of her one child via C-section in 20XX. No complications.
Family History- History reviewed.
-Mother (Alive, 88-years-old): HTN -Father (Alive, 88-years-old): Diabetes -Siblings: N/A -1st^ Child (Alive, XX-years-old): Healthy -Maternal and Paternal Grandparents: FH and medical conditions unknown by patient
Social History
-Alcohol: Does not drink/Denies use -Drug use: Denies current or previous use of recreational drugs
- Tobacco/Smoking/Vaping: Denies tobacco use, smoking, and vaping. Denies 2nd^ hand smoke exposure.
- Caffeine use: Drinks 1 cup of coffee in the morning. Denies consuming any other caffeinated products.
- Occupation: Is an elementary teacher at a nearby school.
- Sleep: Denies any sleep disturbances
- Diet/Physical Activity: Prior to 1 month ago, had not been partaking in any regular, daily exercise or activities. One month ago, she was able to start routinely swimming again, as she enjoys this activity and has done this in the past for exercise. Was eating more fast food and going out for meals often initially upon moving to the area but has now started preparing meals at home and been watching her diet, trying to eat a healthier and well-balanced diet. No special intolerances or diet restrictions. Takes daily multivitamin.
Objective
Vitals
B/P: 148/90 Temp: 98.8 F. Pulse: 78 Respirations: 18 Height: 5’2” Weight: 225 lbs. BMI: 41.
Physical Exam
General : X. X. is a 52-year-old female that appears her recorded age and is in no visible distress or discomfort. Erect and relaxed posture, well-groomed, and answering questions appropriately. Head, Face, & Nose: Head normocephalic and atraumatic. Temporal arteries palpated with +2 pulses bilaterally- no tenderness, argues vessels, masses, or hardness. No bruit on auscultation. Nares patent bilaterally with firm, pink turbinates bilaterally, non-edematous and atraumatic. No nasal discharge or congestion. No frontal or maxillary sinus tenderness. Eyes: Vision grossly intact. Extraocular movements intact, with full range of smooth and coordinated movements bilaterally. PERRLA- 3 mm bilaterally. Corneal light reflex equal and intact. Conjunctiva clear, pink, and moist. Sclera white with no corneal deviation. Retinal red reflex intact bilaterally. Fundi visualized, creamy yellow and orange in color, margins sharp, crossing of arteries/veins, with vessels present in all 4 quadrants-no vessel nicking/narrowing, hemorrhages, or papilledema. Ears: Hearing grossly intact. Left and right external and internal auditory canals WDL and unobstructed. Tympanic membrane pearly-gray bilaterally with typical landmarks visualized, cone of light at 5 o’clock in right and 7 o’clock in left. No effusions, injection, or erythema. Mouth, Throat, & Neck:. Buccal mucosa pink and moist. Gingiva pink and firm with well-defined teeth margins. Tongue light pink, moist, and midline, no tremor or fasciculation Oropharynx clear, tonsils 1+ without exudates. Neck supple with full and symmetrical ROM. Trachea midline. Thyroid palpable and moveable with smooth, noiseless swallow- No enlargement, nodules, or tenderness. Occipital, cervical, clavicular, axillae, and femoral lymph nodes non-palpable and non-tender throughout. No redness, streaks, warmth, or pain in node areas. Cardiovascular: S1 and S2 clearly defined and WDL, regular in rate and rhythm. No adventitious sounds, murmurs, rubs, or clicks. No JVD. Carotid pulses +2 and equal bilaterally, with no bruits auscultated. Upper and lower extremities warm with pulses +2 and equal bilaterally. No edema or varicosities noted and capillary refill <2 seconds throughout. Respiratory: Easy, even, regular breathing. Lung fields resonant on percussion in all right and left lobes. Breath sounds clear and equal bilaterally, with good aeration heard throughout. No wheezing, crackles, rhonchi, or decreased breath sounds.
Breasts: Tissue and size proportionate and symmetrical bilaterally- no lesions, nipple abnormalities, nipple discharge, deformities, growths, skin discoloration, erythema, or skin dimpling. No swelling, tenderness, abnormal tissue, or palpable masses noted. No surrounding lymph nodes palpable. Abdomen: Soft, flat, and non-distended with good muscle tone. Bowel sounds active in all 4 quadrants. Liver edge and spleen nonpalpable. No right or left CVA tenderness. No abdominal bruit over major vessels. No masses, tenderness, hernias, or organomegaly palpated. GU & Pelvic Exam: No tenderness noted on bimanual exam, uterus and ovaries nonpalpable, with no organomegaly, adnexal masses, or abnormal findings noted. External genitalia symmetrical and atraumatic. Anal and urethral openings of normal location and characteristics. No cystocele, rectocele, or other obvious deformities noted. Labia majora & minora and external area of the vaginal canal having some excoriation, redness, and irritation noted on external labia bilaterally. Internal vaginal mucosa pink with some areas of erythema. Moderate amount of white, thick, curdy, non-odorous vaginal drainage noted throughout internal vaginal canal, with no lesions, growths, or ulcers. Cervix visualized via speculum examination and pink, soft, nonedematous, nonerythematous, mobile, and atraumatic. Cervical os inspected & WDL, with no discharge noted in or around opening. No cervical motion tenderness or pain with palpation. Rectal exam deferred. Musculoskeletal: Grossly intact with steady and even gait, coordinated actions, and equal, symmetrical movements. Muscle tone WDL. Spine in alignment with no deformities or asymmetry. Hips appear symmetrical and equal height. Movements are smooth and well-controlled. Neurological: Grossly intact with no focal deficits. Mental Status: Oriented X4-to person, place, time, and situation. Patient alert, attentive to questions, and displays appropriate facial expressions. Verbal and nonverbal responses appropriate. Speech is clear, smooth, and distinct. Depression-PHQ 9 and anxiety-GAD 7 screenings negative (should have asked about this).
Encounter Labs/Diagnostics:
Vaginitis Swab/Wet mount- Negative for trichomoniasis and bacterial vaginitis (clue
cells). Positive for hyphae/budding yeast.
CBC- WDL
CMP- All WDL except for FBG level of 212 (H)
Lipid Panel- WDL
TSH- 1.25 (WDL)
Hgb A1c- 8.2 (H)
Urinalysis- All values WDL except for some yeast present
Assessment/Plan
XXX is a 52-year-old patient here for acute vaginal complaints originally. She is a new patient
wanting to establish care with me as her PCP. Her current chronic conditions are not controlled,
which require changes to her current treatment plan of care. Additionally, multiple health
maintenance activities and health care gaps were discussed and addressed this visit.
3. Essential hypertension not at goal this visit. Goal of < 120/80. Increased daily lisinopril dose to 10 mg daily. Patient to take one 10 mg tablet of Lisinopril daily. Instructed to take blood pressure once daily to assess for positive changes and to allow monitoring for in significant increases or decreases in BP. Record daily blood pressures and bring the readings log with to follow-up visit in one month. If not controlled on 10 mg, may consider increasing the dose further or adding an adjunct medication. Discussed heart healthy diet and physical activity recommendations. Encouraged getting adequate sleep and managing stress with positive coping mechanisms and relaxation activities. **Guideline used from International Society of Hypertension. (Unger et al., 2020) 4. Patient gained 20 pounds over the last year, which increased her BMI to 41.1. Healthy and well-balanced diet that is low in calories discussed with patient and physical activity recommendations also given Instructed that weight loss would be extremely beneficial in controlling both her hypertension and Referral placed to dietician. Weight loss management options discussed, including that a GLP-1 medication for her type 2 diabetes would assist with weight loss and help to control her blood sugars as well. 5. Fasting lipid panel ordered this visit and WDL. Screen for hyperlipidemia NEGATIVE. Will continue to screen for this yearly based on her comorbidities and risk factors for CVD. 6. TSH ordered this visit and WDL. Screen for thyroid disease NEGATIVE. 7. Patient due for colonoscopy to screen for colon cancer. Order placed this visit and pre-operative physical exam scheduled. Once completed, will discuss results with patient. 8. Patient overdue for mammogram screen. Ordered this visit and scheduled. Will call patient with results once completed. **Health maintenance and screening guidelines used from American Family Physicians and the Women's Preventive Services Initiative. (Paladine et al., 2021; Phipps et al., 2019) Follow-Up Plan: Patient to follow-up in one month for a diabetes and hypertension recheck. Will obtain a FBG level at this time, so patient instructed to arrive fasting. Will likely add an adjunct diabetic and weight loss medication this visit, as increasing the metformin to maximum dosing likely won’t result in meeting BG and A1C goals with her A1C this visit being 8.2. If hypertension still not at or near goal, will increase does to 20 mg, with the next step if uncontrolled will likely include adding a thiazide diuretic or CCB. Instructed to follow-up sooner with any continuation of vaginitis symptoms despite treatment or new/worsening symptoms, any significant hypertension or hypotension, with any BG levels over 300, BG levels below 60 not responding to intake of carbs/sugar, and any signs of hypoglycemia such as dizziness, syncope, headaches, fatigue. Orders placed this visit: *Labs: CBC, CMP, TSH, HgbA1c, Lipid Panel, U/A, Vaginitis swab/wet mount
*Fluconazole 150 MG tablet. Take 1 tablet now to treat vaginitis. Ordered- 1 tablet. Refills: 0 *Metformin 500 MG tablet. Take 1 tablet by mouth twice daily with meals. Ordered- 60 tablets. Refills: 0 *Blood Glucose Monitoring Suppl DEVI 1 units *Glucose blood VI test strips (TRUETEST)- adjust number supplied based on insurance coverage
- Lancets Super Thin, 28G MISC 1 Units, 2-3 times daily for 100 doses/lancets. *Lisinopril 10 MG tablet. Take 1 tablet by mouth daily. Ordered-30 tablets. Refills: 0 *MAMMOGRAPHY TOMO SCREENING BILATERAL Standing Status: Future Order Specific Question-Reason for Exam is screening breast cancer *COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; DX, W/ WO SPECIMENS/ COLON DECOMP (SEP PROC) Standing Status: Future Order Specific Question-Reason for Exam is screening for colon cancer *REFERRAL to Dietician for diabetes and obesity management and nutrition education *REFERRAL to Diabetic Nurse Educator for formal diabetic management teaching
infection?search=vaginitis%20management&source=search_result&selectedTitle=2~
&usage_type=default&display_rank=2#H
Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N. R., Prabhakaran, D., Ramirez, A.,
Schlaich, M., Stergiou, G. S., Tomaszewski, M. J., Wainford, R. D., Williams, B., &
Schutte, A. E. (2020). 2020 International Society of Hypertension Global Hypertension
Practice Guidelines. Hypertension, 75, 1334-1357. DOI:
10.1161/HYPERTENSIONAHA.120.15026.
