SOAP Note: Vaginal Thrush

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.

Head: Normocephalic presentation with no lesions.

Eyes:  PERRLA.

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.

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.

Final Diagnosis

· 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.