NURS 6551, WEEK 11 SOAP NOTE 3 (CORRECT-FINAL).

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Patient Information: Initials: D. O. Age: 25 Sex: Female Race: African American (AA) SUBJECTIVE: Chief Complaint (CC): “I have an increased vaginal discharge with severe itching and irritation ... for 2 weeks.” History of Present Illness (HPI): 25Y/O AA female visits the clinic with complaints of increase vaginal discharge, thin gray, white or greenish color, fishy smell, severe itching, lower abdominal pain and back pain started 2 weeks. She reports pain scale on both ailments as 8/10 intermittently but got relieved after taking OTC medication Tylenol 500mg every 6 hours as needed. The patient verbalized no relieve for vaginal discharge and itching. Also, the patient is here for the prenatal follow-up. The patient is G3P1SAB1, LMP-4/8/2019, EDD-1/13/2020, 36weeks gestation of pregnancy. She denies any vaginal bleeding, no leakage of fluid, no contractions, no fever, no urinary frequency, no painful urination, and no painful intercourse. She is sexually active with two partners and do not use condom. OB/GYN History: Menstrual History: Age at menarche – 13 years LMP – 4/8/2019 Menstrual Pattern: Cycle length: 30 days Duration of flow: 4 to 5 days in a month Amount of flow: Moderate Associated pain: None Intermenstrual bleeding: None Perimenopause/Menopause: None Contraception: Current method: None Previous methods: Birth control oral pills Cervical & Vaginal cytology: Most recent Pap smear– November 6, 2017 History of abnormal Pap smear – Not applicable Infections: History of Chlamydia in the past-Treated No history of pelvic inflammatory disease Fertility/Infertility: Desire for future fertility: Yes Sexual History: Type: Heterosexual, sexually active, single partner, unprotected sex Denies history of sexual abuse or assault Obstetric History: G – 3, P – 1, T – 1, A – 1, L – 1 Maternal, fetal, or neonatal complications: None Past Medical History (PMH): Current or Past illnesses: HTN, Asthma, and mild Anemia. Pap smear done on 7/8/2019. Patient immunization is up-to-date. Hospitalizations: None Past Surgical History: Past gynecologic surgeries: None. Past non-gynecologic surgeries: None Medications and Allergies Prescribed Medications: Tylenol 500mg 1 tab Q 6hrs as needed for pain -OTC Albuterol inhaler inhaled 2 puffs orally Q 4-6hrs PRN for cough/wheezing/shortness of breath. Over-the-counter medications: Tylenol 500mg 1 tab Q 6hrs as needed for pain [Show More]

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