Ashley McCammon, MSN Nurse Educator

Focused Diagnosis and Student

Treatment Plan SOAP S: SUBJECTIVE DATA 3/7/2021
CC:
NURS _607_Constitutional
“I am having gray colored vaginalDenies discharge.” weakness, chills, or fever. Denies any recent weight Patient:
gain. Does S.F.
report minor fatigue.
Physical Head General Appearance Ms.
Denies SF is a young-adult,
headache, well-nourished
congestion, female who is alert,
HPI: Patient is a pleasant 19 y/o Caucasian female who presents to thedizziness,
ED complaininglightheadedness
of vaginal or discharge
past head for
Exam the last three days that has worsened cooperative,
trauma. and pleasant. She is oriented to person,
over the last 24 hours. She is sexually active, but denies a steady place, and time
Eyes
boyfriend/partner. Does report sheDenieswith intelligible
pain, redness,
had unprotected speech. She
sex excessive appears
4 days agotearing, in no apparent
double
after going outorwithdistress.
blurred She
somevision,
friends.isspots,
She
describes it as a thin gray well-groomed
specs,
discharge with ora flashing
minor and appropriate.
lights.
fish-like Reports
odor. It overdue
is heavy for eye
enough exam.
she has to use a panty
Laboratory test(s) Perform vaginal swab. Scan saline wet mount to test to confirm/rule out bacterial vaginitis
ROS Ears, Head
liner. Nose,
She denies
Mouth, anyThroat
pelvic or abdominal
Ears: discomfort,
Denies pain, but doesdrainage/discharge,
tinnitus, report itching. Denies fever, chills, or N/V.
and/or diagnostic (BV) and Trichomonal vaginitis. To confirm/rule out BV, perform avertigo, vaginal or pHhearing
(looking for
tests: She has not tried any medications to see
changes. if symptoms resolve, but states that a warm bath does relieve the
pH of greater than 4.5 to confirm) and KOH test (whiff test for amine odor). Perform swab
itching. Denies irregular vaginal spotting
Nose: or bleeding,
Denies drainage, although cycle has
congestion, nosebeen abnormal since having the
placedand
MirenaEyes in culture cervix
July 2020. LMP and6 vaginal
weeks discharge
ago. to test for presence ofbleeds, stuffiness,
any current STIs.orRule
sinus out
pregnancy with dipstick trouble.
since patient LMP was 6 weeks ago. If patient agreeable, HIV/HSV
testing. Mouth/Throat: Denies pain, dry mouth, hoarseness, frequent sore throats,
CurrentENT,
Medications:
Mouth
Health Adderall XR 30mg I would daily theor
po counsel dentalon
patient abnormalities.
smoking cessation Last dental
givenvisit Decembersmokes
she currently 2020. ½ ppd and her
Neck Denies stiffness, lumps, pain, or swollen nodes.
He

Promotional increased health risks of cancer, stroke, and heart and lung disease. I would also counsel
Allergies:
Neck No known
Activities: Cardiovascular patient allergies
on alcohol and
Deniesdrugchest abusepain,prevention givenshortness
palpitations, she drinksofheavilybreath,on weekendsedema,
orthopnea, and
Tobacco Use: occasionally
½ pack per year smokes marijuana.
elevated blood Binge
pressure,drinking can leadcardiac
or previous to poorhistory
judgement and decision
or workup.
Alcohol and Drug
Respiratory Use:IBinge
making. woulddrinks
also alcohol
discuss
Denies on the
safe
shortness sexofweekends,
practices prefers
and
breath, chest vodka cough,
prevention
tightness, and cranberry.
of STIs and HIV
wheezing, Has orabout
given 5-6
patient
sputum
drinks Cardiovascular
3 days ahas week; occasionally
multiple Chest
smokes
sex partners.
production.isI would
symmetric,
marijuana.
encourage without scars or
condom useirregularities.
given that her NoIUD JVDdoesor not protect
Breast against STIs or HIVpulsations.
and is lumps,
Denies notNormal
100% pain, effective
S1orand in preventing
S2,
discharge. withDoes regular pregnancy.
not rate I wouldNo
and rhythm.
perform self-exams. also discuss
PMH Childhood nutrition
illnesses: and
Denies exercise
chickenpox,with
murmurs noted. the
scarletpatient
or as she
rheumatic has an
fever, elevated
and BMI
measles. and
All makes poor
vaccinations dietary
are
Gastrointestinal Denies abdominal pain, N/V/D, trouble swallowing, excessive belching
: and upchoices.
currentRespiratory to date. Thorax is symmetric
or pain.with good good.
expansion. Lungs resonant. Bilateral
Adult Illness: ADHD (2009), anxiety or flatulence,
(2017) Appetite Denies recent change in bowel
breath sounds clear with a regular rate.
habits.
Health Maintenance: Flu vaccine, October 2020. HPV vaccine series complete in 2014. No mammogram or
Genitourinary
pap smear
Breast
to date. Patient does reportDenies
Symmetric, dysuria,
anxiety soft. hesitancy,
at times
No masses;
and ADHDflank
nipplespain, isincontinence,
thatwithoutcontrolled
discharge.or hematuria.
with medication.Denies
any history of STI’s or concerns regarding HIV infections. Reports gray
PSH Tonsillectomy
GI (2010) tinged vaginal discharge and itching. Denies sores or lumps. Menarche
started at age 13. Patient is sexually active and has the Mirena IUD
(placed January 2020). First sexual encounter was at age 17. LMP was 6
FH Father: GU/Rectal
alive, HTN Bilateral
weeks ago, shotty inguinal
lasting 5 days.adenopathy.
She currently External genitalia
has three sexual without
partners, all
Mother: alive, no known health issues erythema,
male. Does report sexual encounters tend to be unprotectedVaginal
swelling, or lesions. Urethral meatus non-tender. after a night
Maternal Grandmother: alive, DMmucosa and cervix coated with thin gray homogenous discharge with
of drinking.
Maternal Grandfather: alive, prostate mild CA fishy odor. After
Musculoskeletal
Paternal Grandmother: alive, HTNcervicalDenies
and MIweakness, jointswabbing cervix,or
pain, stiffness, noarthritis.
discharge visible in the
OS. Cervix is high, soft, and non-tender. Uterus midline,
Integumentary
Paternal Grandfather: deceased, lung Denies
CA at rash, sores, itching, dryness, or changes in color.
68enlarged.
smooth, not No adnexal masses. Rectovaginal wall intact.
Neurological/Psychiatric Denies changes
Rectal vault without masses,in mood, speech,
stool headaches,
brown. pH dizziness,
of vaginal or attention.
discharge > 4.5.
Denies tremors, seizures, syncope, weakness, or numbness. Patient does
SH Musculoskeletal
Patient was born and raised in Hammond, report sheLa. hasSheADHD,is a full-time
diagnosed student at the
in 2009, local
that university.with
is controlled She herresides
on campus in the dormitory and iscurrent currently single. She works at a local restaurant.
Adderall regimen. Denies stress, nervousness, or mood swings. She smokes ½ ppd x1
year and drinks “a lot” of alcohol Denies
Skin on the weekends with herorfriends.
suicidal ideations feelings Sheof reports vodka as her drink of
worthlessness.
choice and has approximately 5-6 Denies
Endocrine drinks aknown night, thyroid
about 3disorder.
nights a week.
DeniesShe also occasionally
heat/cold intolerance,smokesexcessive
marijuana. Denies depression or suicidalsweating, polyuria,She
ideations. or does
excessive
reportthirst/hunger.
a history of anxiety, although she
reportsNeurological
that is well controlled withDenies
Hematologic/lymphatic seeingany her bleeding,
therapist regularly.
adenopathy, Shehistory
does enjoy
of bloodgoing out with friends
transfusions, easy
and going to school. Patient reports bruising,
5-6 hours or anemia.
of sleep a night. Denies any religious affiliation. Gets
Allergic/immunologic
minimal exercise and follows a regular
Denies diet.
allergies
She does
or immunocompromised
report that diet consists state.
of mainly pre-packaged
Endocrine
food and fast food due to convenience; however she does state that she needs to make better choices and
lose weight. She feels safe in her current setting.
Hematologic/lymphatic