Introduction
In the course of completing the practicum project, one has to deal with a number of cases within a day. As a result of this, it may be really difficult for that individual to carry out a comprehensive assessment on every patient seen in the course of the day. However, several tools are in place to enable nurse practitioners to take notes during their shift and to assess them afterward for the purpose of follow-up and future reference. This will allow for more individualized and better care of the patient under assessment. Through the use of these effective tools, such as SOAP notes (Subjective data, Objective data, Assessment and Plan), a nursing practitioner is not only able to make meaningful notes but to also carry out a comprehensive assessment of the patient.
This paper aims to make a comprehensive assessment of a patient I attended to in the course of completing my practicum requirements, using SOAP notes I made during the assessment of the patient. The paper employs a systematic process that comprehensively discusses the patient information, their current health status, patient history, review of the patient’s systems, tests, diagnosis and the treatment plan provided for the patient. This process loops in all the requirements needed when attending to patients from when you meet them to the follow-up stage.
General Patient Information
The patient I attended to was a 24-year-old female of Black American descent. She said that she was in a monogamous relationship.
Current Health Status
The patient presented herself to the clinic with a gray vaginal discharge, which was odorous and had been present for four days. According to the patient, her condition had worsened over the last two days with the severity escalating after urination and sexual relations. The other associated symptoms included itching and a fishy odor from the discharge. The patient stated that she had tried over-the-counter remedies such as Monistat with no improvement of the condition.
The patient indicated her last monthly period was on the 3rd of May, 2014. Her age of menarche was 12 years and she had a regular 28-day menstrual cycle. The patient stated she had been in a monogamous relationship for the previous year and her method of contraception was condoms but admitted that she had not used any protection the previous 2 times she had sexual relations. She also admitted to vaginal and oral sexual intercourse with men only.
Patient History
The patient stated that she had no past medical history and no past surgical history. In addition, the patient did not have any history of psychological and mental health illnesses or disorders. She was not on any medication and is allergic to Sulfa drugs. The patient claimed that she had not had any immunizations since childhood.
In her family history, both parents were alive. The patient’s mom had a history of hypertension while her father had a history of non-insulin-dependent diabetes mellitus. Both grandparents are dead. Her grandmother died of a stroke at the age of 77 and her grandfather died of a myocardial infarction at 69. The patient has 2 younger siblings who were both healthy.
The patient’s gynecologic history is as follows: she has not given birth and has not had a history of sexually transmitted infections and sexually transmitted diseases.
The patient’s personal and social history is as follows: she has no history of tobacco and drug use, but she admitted to having been using alcohol socially on the weekends. The patient lives alone in an apartment and works as a cashier part-time and goes to school full-time. She does regular aerobic exercise 3-4 days a week and loves to run and explore walking trails.
Review of Systems
A review of the various systems was conducted on the patient in order to address the history of the present illness as well as the chief complaint of the patient under assessment. The review was based on a number of questions administered to the patient. The answers given by the patient helped to examine various systems within the patient’s body. A general review revealed that the patient did not have any changes in mood, appetite, fatigue or fever. An assessment of the skin showed that the patient had no rashes, lesions, sores, itching or dryness. A HEENT examination showed that the patient had no headaches. In addition, the patient had not experienced any changes in hearing and she did not have ear pain or ringing in the ears. In addition, the patient did not have nasal congestion, bleeding or drainage. She also did not experience any changes in the sense of smell. An examination of the throat showed that the patient showed no signs of sore throat, dysphagia, or hoarseness. The patient also denied tooth pain, bleeding gums or a dry mouth.
A review of the patient’s neck established that there was no tenderness, nodules or mass. An examination of the breasts showed that there were no breast tenderness, mass or lesions and nipple abnormality or discharge. The review of the respiratory system established that the patient did not have a cough, sob, hemoptysis, or pain upon inspiration/expiration. A cardiovascular exam showed that the patient did not have chest pain, hypertension, irregular pulse, or palpations. A gastrointestinal examination established that the patient did not experience the symptoms of nausea, vomiting hematemesis, or abdominal pain. The patient also denied having heartburns or changes in the bowel pattern.
An examination of the patient’s peripheral vascular system revealed that the patient had no leg pain, leg swelling, claudication or discoloration. A urine test showed the absence of dysuria, hematuria, or change in urinary frequency or incontinence. A musculoskeletal examination showed that the patient did not have muscle pain, arm or leg weakness, joint swelling or arthritis. A psychiatric exam eliminated the possibility of anxiety, depression or mania. A similar neurological showed no signs of syncope, seizures, disorientation, or difficulty with balance. In a hematologic review, the patient denied any bleeding or bruising. An endocrine exam showed that the patient did not have heat or cold intolerance, denies sweating, polyuria, or polydipsia.
The final examination was related to the history of the present illness. During a genital examination, the patient complained of vaginal itching and grayish discharge. However, the patient did not have any change in libido and did not experience any pelvic pain. Additionally, the patient was not pregnant and she did not experience irregular menses.
Physical Exam
A physical examination was also conducted on the patient. This sought to examine the patient’s vital signs, height, weight and BMI. The patient’s vital signs were: her temperature was 98. 1 degree Fahrenheit, her heart rate was at 98, her blood pressure was 18/68, and her respiration rate was 20 times per minute. The patient’s height was 6’2 inches and she weighed 125 lbs. Her BMI was 19.6. Generally, the patient was awake, alert and oriented to the date, place and person. She appeared well-groomed with normal posture, steady gait and no acute distress. Her skin was intact, warm, pink and dry. There were no rashes, petechiae or ecchymosis noted.
A HEENT examination showed that the patient’s head was normacephalic. The eye exam showed that there were no vision changes, eye redness or drainage noted. An examination of the ear showed that the tympanic membranes were clear and the patient had normal hearing. The throat exam showed that the oral mucosa was pink, and it was noted that there were no lesions or ulcers or missing teeth or odor in the mouth. The patient’s skin was soft. No carotid bruit, palpable mass or nodule was noted in the neck examination.
An examination of the chest and lungs of the patient revealed that the thorax was symmetrical and there was symmetrical expansion. It was also noted that there was no use of accessory muscles or increased respiratory effort. The breathing sounds of the patient were vesicular to auscultation and no adventitious sounds were noted. A cardiovascular examination revealed that there was a regular rate and rhythm. It also showed that S1 (first heart sound) and S2 (second heart sound) are normal in auscultation and there was no murmur, rub or gallop noted.
An abdominal examination showed a soft non-tender and non-distended abdomen with active bowel sounds. A musculoskeletal exam showed a normal range of motion, with a normal strength of 5/5 and thus she is able to move against gravity and accept full resistance. Additionally, no deformities and joint stiffness were noted in the patient. A neurological exam showed that cranial nerves 1 through to12 were intact, alert and appropriate. The patient’s speech was clear and her sensation intact.
Finally, a genital examination, which addresses the patient’s chief concern, was conducted. The vulva and Bartholin glands were normal and no atrophy or lesions were noted. The vagina had a grayish odorous discharge coating the walls of the vagina. However, there was no evidence of prolapse. The cervix wall had no lesion or masses and no ovarian tenderness swabs were obtained. The anus was also intact and no hemorrhoids or fissures could be noted.
Laboratory Tests and other Diagnostics
The following diagnostics were used to ascertain the medical condition the patient was ailing from Complete Metabolic Profile (CMP), Complete Blood Count (CBC), Human chorionic gonadotropin (HCG) and Potassium hydroxide (KOH). Other tests such as the Urine Analysis, Wet prep, gram stain and Pap smear were also used in making the diagnostics. Diagnostics play a huge role in the medical sector as they provide objective information about a patient’s health. They are performed by acquiring samples from the body and performing laboratory tests on them. Diagnostics are used to determine the likelihood that a medical condition or illness is in the patient’s body. They are also used to monitor the response of patients to treatment administered and sometimes to even guide the physician in deciding to conduct more tests and treatments (AdvaMedDx, 2011).
Differential Diagnoses
Differential diagnosis is a technique that identifies different diagnostic alternatives and then applies an elimination process that concludes with the most suitable diagnosis (AdvaMedDx, 2011; Ferri, 2011). The differential diagnostics I made for this patient included: Chlamydia, Gonorrhea, Trichomoniasis and Bacteria Vaginosis. These diagnoses are made from the initial symptoms presented by the patient. These are: a fish odor in their virginal discharge, itching and gray color of the discharge
Chlamydia is difficult to diagnose in women because about 70% of women who have it do not show any symptoms (Centers for Disease Control and Prevention, 2010). The symptoms of Chlamydia that occur in women include a burning sensation during urination, vagina discharge, pain during sexual intercourse and rectal pain or discharge. However, these symptoms differ from those presented by the patient as the patient’s vaginal discharge had a fish odor and it was grayish in color. As a result, Chlamydia is ruled out as a diagnosis.
Most women with gonorrhea do not have symptoms. However, some of the symptoms that may show include painful or burning sensation when urinating, vaginal bleeding between periods, increased vaginal discharge and rectal infections that may cause discharge, itching, soreness, bleeding and painful bowel movements (Centers for Disease Control and Prevention, 2010). The symptoms presented by the patient differ from those of gonorrhea because of the smelly discharge. Therefore, gonorrhea is ruled out.
Trichomoniasis is a sexually transmitted infection that majorly affects women in the vagina and urethra. Its symptoms are abnormal discharge which may be thick, thin, frothy or yellow-green in color, producing more discharge than normal, which may have an unpleasant fishy smell, soreness, inflammation, itching, and pain during sexual intercourse and pain in the lower abdomen (Centers for Disease Control and Prevention, 2010). Although the symptoms presented by the patient are very closely related to those of trichomoniasis, they differ in the color of the discharge. The patient’s discharge is gray while that of trichomoniasis is yellow-green in color.
Bacteria vaginosis shows no signs and symptoms in around half of women who have it. However, those that get the symptoms experience a change in their usual vaginal discharge. This may increase, become thin and watery, change to a white/gray color and develop a strong, unpleasant, fishy smell, especially after sexual intercourse (Centers for Disease Control and Prevention, 2010). Bacterial vaginosis is usually associated with soreness, itching or irritation. The diagnosis I chose for this patient is bacterial Vaginosis because of the symptoms and because Amel’s clinical criteria for diagnosis require three of the following; a fish odor, a pH of 4.5, the presence of clue cells on microscopic examination, or a discharge that coats the vaginal walls, and the absence or decreased lactobacilli.
Management Plan Diagnosis
After establishing that the symptoms are similar to those of bacterial vaginosis, several tests are carried out to confirm this. The diagnosis of bacterial vaginosis is done through a pap smear test which involves collecting a sample of vaginal discharge using a swab and measuring its pH (Family Planning Association, 2014). The discharge is also studied using a microscope to check for bacterial vaginosis. The STI can also be detected through cervical screening.
Treatment
Bacterial vaginosis is treated through taking antibiotic tablets, such as metronidazole (Family Planning Association, 2014). The medical practitioner may also recommend a cream or gel, which is applied to the vagina. However, for most women, bacterial vaginosis goes away on its own.
Patient Education
In this context, patient education would be important in educating the patient about the various ways she could achieve better health outcomes. The following measures would be proposed to the patient:
- Help keep your vaginal bacteria balanced. Wash your vagina and anus every day with mild soap. When you go to the bathroom, wipe from your vagina to your anus. Keep the area cool by wearing cotton or cotton-lined underpants.
- Avoid tight pants and skip the pantyhose in summer.
- Do not douche. Douching removes some of the normal bacteria in the vagina that protects you from infection. This may raise your risk of BV. It may also make it easier to get BV again after treatment.
- Have regular pelvic exams. Talk with your doctor about how often you need exams, as well as STI tests.
- Finish your medications. If you have BV, finish all the medicine your doctor gives you to treat it. Even if the symptoms go away, you still need to finish all of the medicine.
- Do not have sex. The best way to prevent any STI is to not have vaginal, oral, or anal sex.
- Be faithful. Having sex with just one partner can also lower your risk. Be faithful to each other. That means that you only have sex with your partner and no one else.
- Use condoms. Protect yourself with a condom every time you have vaginal, anal, or oral sex. Condoms should be used for any type of sex with every partner. For vaginal sex, use a latex male condom or a female polyurethane condom. For anal sex, use a latex male condom. For oral sex, use a condom or a dental dam. A dental dam is a rubbery material that can be placed over the anus or the vagina before sexual contact.
- Talk with your sex partner(s) about STIs and using condoms. It is up to you to make sure you are protected.
Follow-up Care
It is important to follow up with the patient on completing her medication and preventing bacterial vaginosis from occurring again in the future. The patient should be encouraged to visit the clinic regularly for checkups and to maintain personal hygiene. Follow-up is also quite important in ensuring that the patient is continuing well with the prescribed medication. This is important given that any failure to complete the medication may lead to a worsening of the patient’s health condition and could lead to resistance of the disease to medication in the future.
Conclusion
In conclusion, the process of comprehensively analyzing a patient’s assessment from the patient information all through to diagnosis and treatment management plan allows the nurse practitioner to see areas that were left out during the actual interaction with the patient. As a result, the nurse is able to make improvements in similar patients. This process also helps the nurse to map out their assessment during one on one interaction with patients in a way that addresses all the issues they require in the comprehensive assessment. As a result, the nurse is able to make a better judgment based on having adequate information about the patient and they are also able to make follow-ups with the patients with ease.
References
AdvaMedDx. (2011). A Policy Primer on Diagnostics. London, United Kingdom: Vita Insights.
Family Planning Association. (2014). Thrush and Bacterial vaginosis: Looking after your sexual health. Florida, FL: FPA.
Ferri, F. F. (2010). Ferri’s differential diagnosis: a practical guide to the differential diagnosis of symptoms, signs, and clinical disorders. Amsterdam, Netherlands: Elsevier Health Sciences.
Centers for Disease Control and Prevention (2010). Sexually Transmitted Diseases Treatment Guidelines. Morbidity and Mortality Weekly Report, 59(12), 1- 130.