SOAP NOTE – VAGINITIS 2
Example of Clinical Log Documentation Date of Visit: 12-2-09 Place: Private Office, Smith Medical Center FYI for instructor: Ms. S is a 58-year-old AFA schoolteacher who has been a patient in this office for the past 8 years. Her medical history consists of HTN and Osteoarthritis of the left hip, which is well controlled on Toprol XL 50 mg 1 po qd and Celebrex 200 mg 1 po qd. She has never been hospitalized or acutely ill. She is a non-smoker with rare glass of wine at dinner with her family. She was seen in the office 2 weeks ago for routine office visit, with no specific complaints, her PE was entirely negative; she was given renewal of her routine medications and Flu Vaccine was administered. CC: I have a urinary tract infection HPI: 7 days ago began to have frequency of urination 5-6 times per day, urine burns when “it hits the skin,” occasional vaginal itching. No relief from increased fluids, cranberry juice. Denies fever/chills. Denies past history of urinary or vaginal symptoms or infections. ROS: General: Denies any changes in health since last visit. Breast/Chest: Denies pain, lumps or massess in breast or axilla, no discharge from nipple. Does not perform SBE. Abdomen: Denies abdominal pain, weight loss/gain, change in appetite, nausea/vomiting, or change in stools. GU: See HPI. Denies change in color of urine, hematuria, urgency, nocturia, back pain, fever or stress/urge incontinence. GYN: Denies pelvic pain, vaginal discharge or bleeding. Does admit to having “brown spots in my underwear sometimes.” Menopausal for past 11 years, does not remember last Pap smear. States, “ It was many years ago when I first became menopausal. I don’t need that because I haven’t had sex since my husband died 10 years ago.” Has yearly mammography, all have been negative. PMH: Hypertension Obesity OA left hip PSH: None Family History: Mother deceased aged 91 from old age Father deceased age 82 from auto accident Husband deceased 1999 from MI Social History: Retired elementary school teacher, Widower, lives alone, no children. Non-smoker, denies elicit drug use, occasional glass of wine with dinner on social occasions. Allergies: NKDA PE: VS: 148 lbs, 63”, 97.2°, 138/70, 72, 16, BMI 26.2 Gen: AAOX3, NAD, affect appropriate to situation, smiling, animated. Skin: clean, warm and dry. Color appropriate to ethnicity. No lesions or masses Breast: Symmetrical, no retractions, nipple discharge or lesions. Countour and consistency appropriate to age. No masses, tenderness or lymphadenopathy. Chest: Non-tender to palpation. Lungs clear to P&A with = chest expansion Heart RR without m, g, r. PMI at 5th ICSMCL Abdomen: Flat, +BS X 4 quads, soft, nontender to palpation, tympanic percussion notes. No lesions, no HSM. GYN/GU: Perineum: clean, dry without lesions, no groin or inguinal Lymphadenopathy; urethra and vulva with post-menopausal changes. No caruncle or prolapse noted. Vaginal canal: moderate amount thick white adherent discharge noted in canal with loss of rugae. Scant amount thin homogenous white-yellow discharge in fornix. Cervix is pink and non-friable. Vaginal culture and thin prep pap obtained. Bi-manual: no pain on palpation of cervix or adnexal structures, ovaries not enlarged. Rectal: anal wink present, stool brown, guiaic negative. In-office Diagnostic testing: Urine dipstick: Color light yellow, Sp gr 1.020, pH 5.5, + leukocyte esterase, negative for all other constituents Wet Mount: + hyphae, + clue cells, many epithelial cells Vaginal PH: 7.0, Whiff test positive. Diagnosis: http://icd9cm.chrisendres.com/ (List all diagnoses that are relevent to the patient with the diagnosis/ses that are the reason for the visit first.) Candida Vaginitis (112.1) Bacterial Vaginosis (616.10) Breast Screening for malignant neoplasm (V76.19) Routine gyncecology sscreening (V72.31) Overweight (278.02) BMI 26.2 (85.22) Hypertensive Heart Disease without failure (402.90) Osteoarthritis left hip (715.15) Differential Diagnoses: Here you will provide a list of differential diagnosis if this is appropriate to the patient situation. Include the diagnosis to be entertained, a brief discussion of the most common presenting signs and symptoms. Is the diagnosis a real possibility and why or why not? How would you rule in or out the diagnosis? R/O UTI: No dysuria, urgency, nocturia, and hematuria. Burning r/t irritation of skin. Vaginal itching present. Dipstick + LE only, normal pH, specific gravity does not promote concentrated urine. Not a high probability in this patient due to symptoms and urine dipstick results. R/O ureteral stone: No sudden onset. No dysuria, urgency, hematuria or flank/pelvic pain. No fever, diaphoresis, nausea or vomiting. No blood on urine dipstick. More common in male patients. Not a high probability in this patient as patient symptoms do not fit the diagnostic category. Plan of Care: Medications, Diagnostic Testing Ordered, and Education/Referrals Diflucan 150 mg 1 po today, #1 with no refills Rationale: Easy to take, 1 dosage all that is needed. Also prescribing a intravaginal cream for BV, it is difficult for patients to use 2 creams at one time. Clinidamycin 7 Vaginal Cream, 1 applicator qhs X 7, no refills Is drug and route of choice in BV. Thin prep, vaginal culture to lab Discussed diagnoses, prognosis and expected course. Discussed medications, side effects and adverse reactions to report to me Continue all other routine medications Perineal hygiene reviewed. Need for regular pap smear every 3 years until age 70 discussed. If all paps are normal then may stop testing. Reviewed heart healthy diet and need to begin exercise program within arthritic limitations and health benefits of both. Handouts given to support discussion. Taught SBE with return demonstration. Handout given to support education discussion. Referral for yearly mammography given to Jones Diagnostic Center Patient verbalizes understanding of all issues discussed. Follow-up: RTO in 5 days if condition does not follow expected course as discussed. If all symptoms have abated follow-up is not necessary. Visit Code: 99213 Teaching Plan: For this patient I would provide a handout on BV as well as how to insert and use intravaginal creams for best results. Evidenced Based Guidelines used to assess this patient CDC STD guidelines: http://www2a.cdc.gov/stdtraining/self-study/vaginitis/vaginitis18.asp National Guidelines Clearinghouse: http://www.guidelines.gov/summary/summary.aspx?doc_id=11602 ACOG Guidelines on the diagnosis of Vaginitis: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10925&nbr=5705 HEDIS guideline: Cervical CA screening ages 21-64. At least 1 Pap Smear every 2 years. In this document You will provide information on 2 patients you have cared for in the clinical situation. Pick one diagnostic test ordered for 1 of the 2 patients and formuate a 1 page-teaching handout that is patient oriented. Self-evaluation To be placed at end of the document. Self-evaluation for the time period: Discuss the one most important event from which you learned something new in the clinical situation during this time frame? How will you use that information in the future? Discuss a diagnostic error or error in judgement you made in the clinical situation. Analyze why you made this error and what you learned from the experience. Where do you need to put more emphasis in your preparation for your role as a NP? Where do you feel you need more guidance? How will you go about gaining this guidance or experience? Discuss any barriers to your role as an NP in this clinical situation, whether this is health care provider, organizational or patient related. How will you approach or intiate any changes that may be needed? Patient Tracking form as a second attachment. It should contain all patients seen up to the time of submission of each log. By the end of the semester this form should be inclusive of all patients seen for the entire semester. Please email your completed form to me at the end of the semester.
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