|Name: S.K||Date: 25/5/2017||Time:|
|Age: 26||Sex: Female|
|CC: S.K has come to the clinic showing signs of good health. However, she says, “My vagina is itching, and I always feel a burning sensation when I have sex.”||You may find this article Nursing SOAP Note Writing Service useful.|
|HPI: S.K was well until last week, when she started feeling slight itchiness in the vagina. S.K says she did not seek any medical attention because the symptoms occasionally disappeared. Five days ago, S.K experienced a burning sensation when she was having sexual intercourse with her husband. She started having dysuria the same day. She did not go to the clinic, thinking the symptoms could disappear. S.K says that yesterday, the itchiness increased, and her vulva was painful upon touch. She also noticed white discharge from the vagina that had an unusual smell. Today morning, she says that her vulva was painful and reddened. The persistence of these symptoms has caused her to seek treatment to alleviate them.|
|Medications: She does not use any medication currently.|
Allergies: S.K does not have allergy to any food, medications, or any other allergens.
Drug Intolerances: S.K does not have any medication intolerances.
Chronic Diseases or Traumas: She has never suffered from any chronic disease, and currently, she reports of no major or minor trauma.
Hospitalizations/Surgeries: S.K has never been hospitalized. She further says that she has never undergone any surgery.
|Family History: S.K is the last-born. She has three siblings, who are all married and have never suffered from any chronic illness. Her mother and father are alive without any chronic diseases. She reports on no history of chronic illness in her grandparents.|
|Social History: S.K is married with two children. The children are all alive and well. S.K does not smoke and never uses any illicit drugs. However, she occasionally drinks wine after dinner. She works as a sells agent, which is her main source of income.|
|General: Denies any recent weight changes, chills, or night sweats.||Cardiovascular: Denies palpitations, edema, claudication, or orthopnea.|
|Skin: Denies any skin discolorations, rashes, or delayed healing of wounds.||Respiratory: No hemoptysis, coughing, or dyspnea identified. Further, she denies ever suffering from TB.|
|Eyes: Denies any changes in vision, use of any corrective lenses, or ever having experienced retinal hemorrhage.||Gastrointestinal: No ulcers, constipation, or loss of appetite. Also, she denies any recent experiences of abdominal pain.|
|Ears: Denies hearing loss, tinnitus, or any discharge.||Genitourinary/Gynecological: Positive for dysuria and active sexual activity. Also, positive for foul-smelling vaginal discharge. Gravida two para two. She does not remember the date of the last Pap test or breast mammography, but she has done each of them once.|
|Nose/Mouth/Throat: Denies any dental diseases, voice hoarseness, nose bleeding, or sinusitis.||Musculoskeletal: No joint stiffness, pain in extremities, or any experiences of back pains. She further denies fractures or any history of osteoporosis.|
|Breast: She understands SBE and does it occasionally. She denies any bumps or lumps.||Neurological: No weakness, seizures, transient paralysis, or paresthesias.|
|Heme/Lymph/Endo: No history of blood transfusion or any endocrine abnormality. Also, denies swollen glands or heat intolerance.||Psychiatric: Denies any experiences of depression or suicidal attempts in her life. She has never had insomnia.|
|Weight: 142lbs BMI :22.9||Temp: 98.3F||BP: 128/75mmHg|
|Height: 5’6”||Pulse: 80bpm||Resp: 18bpm|
|General Appearance: A young female that appears healthy without any distress. She understands the clinic environment but is in a slightly somber mood.|
|Skin: Clean, brown, and intact without any rashes or lesions.|
Head: Normocephalic presentation with no lesions.
Ears: Normal auditory canal with clear landmarks.
Nose: No septal deviation; pink nasal mucosa with normal turbinates.
Neck: Supple with full ROM.
Mouth and Throat: Inner mouth is pink and moist, and the pharynx does not produce any exudates.
|Cardiovascular: No heart murmurs, pulses are 3+, no edema is seen, and the heart has a regular rhythm.|
|Respiratory: Regular and easy respiration with clear bilateral lung sounds.|
|Gastrointestinal: She has active bowel sounds without abdominal obesity. No hepatosplenomegaly or abdominal tenderness noted.|
|Breast: No masses or tenderness identified upon palpation.|
|Genitourinary: She has foul-smelling white vaginal discharge. The vulva is swollen and reddened. The vaginal introitus has rashes. The bladder is palpable.|
|Musculoskeletal: She has full ROM in all joints.|
|Neurological: Clear speech with good tone and erect posture.|
|Psychiatric: Oriented, kempt, maintains eye contact during history taking, and she answers questions appropriately.|
|Lab Tests: The nurse has taken a sample of vaginal discharge and sent them to the laboratory. The results of the wet mount test of vaginal discharge are positive for Candida.|
|Special Tests: Examination of vulva reveals reddened and swollen labia majora and labia minora. A pelvic exam has been conducted, and it reveals the production of thick white discharge that has an unusual smell. It also shows the presence of a vaginal rash.|
| Differential Diagnoses
The subjective history shows that S.K has itchiness on the vulva and in the vagina. Objective history reveals reddened vulva with a vaginal rash. There is also the production of foul-smelling vaginal discharge. Therefore, the differential diagnoses would be:
· Trichomoniasis due to its ability to cause genital swelling.
· Gonorrhea due to its capacity to cause the production of foul-smelling discharge.
· Vaginitis due to its ability to cause redness of vaginal introitus.
· Vaginal Thrush. The subjective history shows that S.K has itchiness of the vulva and the vagina. The objective history further reveals reddened vulva. Then, the lab tests show that the discharge contains increased amount of Candida. According to Cassone (2015), the presence of Candida in inflamed vulvovaginitis signifies vaginal thrush.
Further testing: The nurse has confirmed the presence of Candida and verified the diagnosis with the inflammation of the vulva. Therefore, further tests are unnecessary. However, the nurse can ask S.K whether she had any vaginal infections previously and whether they were treated well. The response of the patient might reveal if the current diagnosis is a complication of past infections.
Medication: The infection has lasted for one week, thus indicating that S.K has uncomplicated vaginal thrush. Therefore, she needs two types of drugs to cure the infection fully. According to Biamonti and Saracino (2017), butoconazole is effective to manage vaginal thrush. Therefore, the nurse can recommend application of butoconazole cream intravaginally twice a day. This medication can weaken Candida cells and kill them, thus curing the infection. Then, Biamonti and Saracino (2017) argue that fluconazole is effective to manage uncomplicated vaginal thrush. Therefore, the nurse can give the patient a single dose of 150mg by mouth. A combination of this medication regimen can guarantee adequate recovery from vaginal thrush.
Non-medication treatments: The nurse can use a mixture of yogurt and honey since it has been proven to be an effective way of treating vaginal thrush. Darvishi, Darvishi, Jahdi, Hamzegardeshi, Goodarzi, and Vahedi (2015) recommend combination of this mixture with vaginal cream to treat vaginal thrush effectively. Hence, the nurse can advise S.K to use such treatment at home.
Education: The nurse can stress the importance of complying with the medication to treat the disease fully because poor adherence can result in resistance of Candida to drugs (Darvishi et al., 2015). The nurse can also advise S.K to observe hygiene and avoid any sexual intercourse until her vaginal discharge test is negative for Candida. Adhering to these recommendations can improve the efficacy of medications and facilitate recovery.
Referral and Follow-up: S.K has uncomplicated vaginal thrush. Therefore, the nurse can manage her effectively without any need for referral. However, the nurse can tell S.K to come to the clinic after three days to assess the treatment progress. If upon the follow-up S.K. does not show any improvement, the nurse can refer her to a gynecologist.