Questions listed below SOAP Focused SOAP Note Template Patient…

QuestionAnswered step-by-stepQuestions listed below SOAP Focused SOAP Note Template Patient…Questions listed below SOAP Focused SOAP Note Template Patient Information:SS, 66, F, Caucasian VS BP 132/86, P74, R16, T98.5, Wt 183.6lbs with clothes, Ht 5’4″S.CC (chief complaint): Dysuria; Painful, burning urination and discharge.HPI: 2 weeks ago, she started having burning with urination, itching, and discomfort in her lower abdomen. She has noticed an increase in urgency and frequency and sometimes she cannot make it to the bathroom. Had unprotected sex with a new partner 1 week ago. She is unsure if he has any symptoms. Swam in a public pool twice last week. Afterwards she started having watery vaginal discharge that is now thick and white without odor. Left labia minora red and tender in addition to redness and tenderness inside the vagina. She used some topical gel that seemed to help a little bit.Location: vaginaOnset: 2 weeks agoQuality: burning; pressure; painSeverity: worsening; pain level 10/10Duration: constantTiming: worseContext: no prior history of STDs; no known exposure to STD; sexually active (unprotected sex with new partner); unsure of STI hxModifying Factors: nothing makes it worse; OTC medication; Unsure of gel that she has usedAssociated Symptoms: no fever; no blisters on genitals; no rash on genitals; no hesitancy; no blood in the urine; no flank pain; vaginal pain; smaller urine streamCurrent Medications:Advair Diskus 250 mcg-50 mcg/dose powder for inhalationalbuterol sulfate HFA 90 mcg/actuation aerosol inhaler ARIPiprazole 10 mg tabletclonazePAM 1 mg tabletDULoxetine 30 mg capsule,delayed releasefluconazole 150 mg tabletfluticasone propionate 50 mcg/actuation nasal spray,suspensiongabapentin 300 mg capsuleloratadine 10 mg tabletmetroNIDAZOLE 500 mg tabletmupirocin 2 % topical ointmentnystatin 100,000 unit/gram topical powderOXcarbazepine 600 mg tabletpantoprazole 40 mg tablet,delayed release prazosin 2 mg capsulerosuvastatin 10 mg tabletSuboxone 8 mg-2 mg sublingual film.Allergies: PCN-anaphylaxis PMHx: hx of Anemia, Anxiety Disorder, Asthma, COPD, Depression, PTSD, Diverticulitis, GERD/Reflux, Hyperlipidemia, Chronic pain·       SARS-COV-2 (COVID-19) vaccine, UNSPECIFIED 04-13-2021·       SARS-COV-2 (COVID-19) vaccine, UNSPECIFIED 03-24-2021·       Tdap 04-18-2019·       influenza, recombinant, quadrIvalent,injectable, preservative free 10-02-2020·       Influenza, injectable, MDCK, preservative free, quadrivalent 12-19-2019·       influenza, injectable, quadrivalent 01-01-2018·       pneumococcal polysaccharide PPV23 04-18-2019 Soc and Substance Hx: Tobacco smoking status: Current every day smoker Smoking – how much: 1/4 PPDSmokeless tobacco status: Never used smokeless tobaccoTobacco-years of use: 50Started age 16E-cigarette/vape status: Never used electronic cigarettesOccupation: partial disableEducation: 12th gradeMarital status: WidowedExercise level: ModerateDiet: RegularGeneral stress level: HighHas smoked since age: 16Alcohol intake: OccasionalCaffeine intake: HeavyChewing tobacco: noneIllicit drugs: ocassional marijuana useGuns present in home: YesSeat belts used routinely: YesSunscreen used routinely: YesSmoke alarm in home: YesAdvance directive: NoLive alone or with others: with others,childFamily Hx: Maternal Grandmother, diabetes mellitus; Father, hx of stroke, malignant tumor of lung, and goutSurgical Hx: Revision of repair of rotator cuff – 01/01/2016, Back Surgery – 01/01/2015, Leg surgery procedure – 01/01/2010, Hysterectomy – 01/01/2000.Mental Hx: Hx of depressive disorder and PTSD treated with aripiprazole 10 mg and duloxetine 30mg. anxiety disorder treated with clonazepam 1mgViolence Hx: No concerns or history of violenceReproductive Hx: LMP: Approximate (Notes: partial hysterectomy 2000). Age at First Child: 17; Age at Menarche: 14, Current Birth Control Method: None; Age at Menopause: 55. OB Total: 3; Full term: 2; Premature: 1ROS: Physical ExamPatient is a 66-year-old female.Constitutional: General Appearance: healthy-appearing, well-developed, and obese. Level of Distress: NAD. Ambulation: ambulating normally. Psychiatric: Insight: good judgement. Mental Status: normal mood and affect and active and alert. Orientation: to time, place, and person. Memory: recent memory normal and remote memory normal. Head: Head: normocephalic and atraumatic. Eyes: Lids and Conjunctivae: non-injected, no pallor, and discharge (watery). Pupils: PERRLA. Corneas: grossly intact and fluorescein stain–normal. Fundoscopic: normal vessels and optic discs, no exudates or hemorrhages, and grossly normal except where noted. EOM: EOMI. Lens: clear. Sclerae: non-icteric. Vision: peripheral vision grossly intact and acuity grossly intact. ENMT: Ears: no lesions on external ear, EACs clear, TMs clear, and TM mobility normal. Hearing: no hearing loss and Rinne AC>BC. Nose: no lesions on external nose, septal deviation, or sinus tenderness and nasal passages clear and nasal discharge–rhinorrhea. Lips, Teeth, and Gums: no mouth or lip ulcers or bleeding gums and normal dentition. Oropharynx: no erythema or exudates and moist mucous membranes and tonsils not enlarged. Neck: Neck: supple, FROM, trachea midline, and no masses. Lymph Nodes: no cervical LAD, supraclavicular LAD, axillary LAD, or inguinal LAD. Thyroid: no enlargement or nodules and non-tender. Lungs: Respiratory effort: no dyspnea. Percussion: no dullness, flatness, or hyperresonance. Auscultation: no wheezing, rales/crackles, or rhonchi and breath sounds normal, good air movement, and CTA except as noted. Cardiovascular: Apical Impulse: not displaced. Heart Auscultation: normal S1 and S2; no murmurs, rubs, or gallops; and RRR. Neck vessels: no carotid bruits. Pulses including femoral / pedal: normal throughout. Abdomen: Bowel Sounds: normal. Inspection and Palpation: no guarding, masses, or rebound tenderness; LLQ tenderness, RLQ tenderness, suprapubic tenderness, and CVA tenderness; and soft and non-distended. Liver: non-tender and no hepatomegaly. Spleen: non-tender and no splenomegaly. Hernia: none palpable. Female GU: External genitalia: no lesions or rash and abnormal (erythematous circular area on perineum). Vagina: moist mucosa and abnormal discharge (thick white). Cervix: deferred. Uterus: deferred. Adnexae: Deferred. Bladder and Urethra: Deferred. Neurologic: Gait and Station: normal gait and station. Cranial Nerves: grossly intact. Sensation: grossly intact and monofilament test intact. Reflexes: DTRs 2+ bilaterally throughout. Coordination and Cerebellum: finger-to-nose intact and no tremor.O.Physical exam: ConstitutionalGeneral Appearance: healthy-appearing, well-developed, obeseLevel of Distress: NADAmbulation: ambulating normally PsychiatricInsight: good judgementMental Status: active and alert, normal mood, normal affectOrientation: to time, to place, to personMemory: recent memory normal, remote memory normal HeadHead: normocephalic, atraumatic EyesLids and Conjunctivae: non-injected, no pallor, discharge (watery)Pupils: PERRLACorneas: grossly intact, fluorescein stain–normalFundoscopic: grossly normal except where noted, normal optic discs, normal vessels, no exudates, no hemorrhagesEOM: EOMILens: clearSclerae: non-ictericVision: peripheral vision grossly intact, acuity grossly intact ENMTEars: no lesions on external ear, EACs clear, TMs clear, TM mobility normalHearing: no hearing loss, Rinne AC>BCNose: no lesions on external nose, no septal deviation, nasal passages clear, no sinus tenderness, nasal discharge–rhinorrheaLips, Teeth, and Gums: no mouth or lip ulcers, no bleeding gums, normal dentitionOropharynx: moist mucous membranes, no erythema, no exudates, tonsils not enlarged NeckNeck: supple, trachea midline, no masses, FROMLymph Nodes: no cervical LAD, no supraclavicular LAD, no axillary LAD, no inguinal LADThyroid: no enlargement, non-tender, no nodules LungsRespiratory effort: no dyspneaPercussion: no dullness, flatness, or hyperresonanceAuscultation: breath sounds normal, good air movement, CTA except as noted, no wheezing, no rales/crackles, no rhonchi CardiovascularApical Impulse: not displacedHeart Auscultation: RRR, normal S1, normal S2, no murmurs, no rubs, no gallopsNeck vessels: no carotid bruitsPulses including femoral / pedal: normal throughout AbdomenBowel Sounds: normalInspection and Palpation: soft, non-distended, no guarding, no rebound tenderness, no masses, LLQ tenderness, RLQ tenderness, suprapubic tenderness, CVA tendernessLiver: non-tender, no hepatomegalySpleen: non-tender, no splenomegalyHernia: none palpable Female GUExternal genitalia: no lesions, no rash, abnormal (erythematous circular area on perineum)Vagina: moist mucosa, abnormal discharge (thick white)Cervix: (deferred)Uterus: (deferred)Adnexae: (Deferred)Bladder and Urethra: (Deferred) NeurologicGait and Station: normal gait, normal stationCranial Nerves: grossly intactSensation: grossly intact, monofilament test intactReflexes: DTRs 2+ bilaterally throughoutCoordination and Cerebellum: finger-to-nose intact, no tremorDiagnostic results: Venereal disease screening- Nucleic acid amplification tests (NAATs) are suggested for the identification of chlamydia and gonorrhea due its high sensitivity and specificity. The test detects the DNA of gonorrhea, chlamydia, and trichomoniasis (Rönn et al., 2019).Check CT + NG DNA, PCR, – chlamydia by NAA negative gonococcus by NAA negative trich vag by NAA positive  Check HIV Ag/Ab with reflex HIV screen 4TH generation wrfx non reactive  Check hepatitis panel, acute- hep A Ab, IgM negative HBsAg screen negative hep B core Ab, IgM negative hep C virus Ab <0.1  Check RPR, rfx qn RPR/confirm TP- RPR non reactive  Urinalysis- When nitrates are positive in the urine, this likely indicates a UTI triggered by gram-negative bacteria. The presence of leukocytes suggests a pathologic microorganism but not necessarily a UTI. Leukocytes without nitrites in the urine could still be an infection that comes from yeast or protozoa (MacGill, 2018).  Leukocytes Small Nitrite negative Urobilinogen .2 Protein Trace pH 5.0 Blood Non-Hemolyzed: Trace Specific Gravity 1.030 Ketone Negative Bilirubin Negative Glucose 100   A.Trichomonas Vaginalis- Trichomoniasis (or "trich") is an extremely common sexually transmitted disease (STD). It is caused by a protozoan parasite called Trichomonas vaginalis. Symptoms of the disease range with different people, but most people are asymptomatic and display no signs of infection. Women that do show symptoms may have mild to severe inflammation such as burning, itching, redness and pain of the vagina accompanied by discharge and dysuria (CDC, 2021). The only way to truly diagnose this condition is with lab test. This diagnosis was ruled in due to a positive nucleic acid amplification test (NAA). Dysuria/UTI- When patients come in with dysuria the first intervention is to check for a UTI. A urinalysis that comes back where nitrates are positive in the urine, this likely indicates a UTI triggered by gram-negative bacteria. The presence of leukocytes suggests a pathologic microorganism but not necessarily a UTI. Leukocytes without nitrites in the urine could still be an infection that comes from yeast or protozoa (MacGill, 2018). This patient's UA showed small amounts of leukocytes and negative for nitrites. For this reason, we ruled out UTI. Candidasis Vulvovaginitis- Candiddasis vulvovaginitis also known as a yeast infection, is very common, especially in women. Patients usually with come in with complaints of itching, burning, vaginal irritation and excoriation of the vulvar skin. Observation of vulvar erythema, swelling and thick white discharge is also common (Jeanmonod, 2020). This patient presented with all the signs of a yeast infection so she was treated empirically with fluconazole. P.  Candidal vulvovaginitisProvided candidiasis: care instructionsStart fluconazole 150 mg tablet 1 tablet onceStart nystatin 100,000 unit/gram topical powder APPLY TO THE AFFECTED AREA(S) BY TOPICAL ROUTE 2 TIMES PER DAYDysuriaReceived urinalysis, dipstick resultsProvided painful urination (dysuria): care instructionsvenereal disease screeningCheck CT + NG DNA, PCR, urineProvided exposure to sexually transmitted infections: care instructionsCheck HIV Ag/Ab with reflexCheck hepatitis panel, acuteCheck RPR, rfx qn RPR/confirm TPeducation about sexually transmitted disease preventionProvided safer sex: care instructionsTrichomonas Vaginalis-metroNIDAZOLE 500 mg tabletProvided safer sex: care instructionsF/u in clinic in two weeks for repeat test to assess efficacy. HIV ScreeingRepeat HIV testing in 3 mths (CDC, 2021).HIV prevention, exposure and s/s educationQuestion:1) What do you think should be the main teaching objectives, of the above Soap, when educating older adults about sex?2) What are some common myths related to sexual behaviors that may put older patients at risk? Health ScienceScienceNursingNUNP 6540Share Question