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):
- 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).
- 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).
- 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, 12th ed. Wolters Kluwer.
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.
Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6th 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, 20th 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