make up a soap note for a female patient with diagnoses of Genital Herpes

A) Please fallow instruction. I need you to make up a soap note for a female patient with diagnoses of Genital Herpes. Please fill out the template. I include the soap note template and use it as a sample, this is the way it has to come out. you must plug the information. do not use the same he same words nor the same vital signs in the sample template, you. make up your own vital sign I need you to provide the following: APA format with references at least no older than 5 years.1)The Diagnosis ICD 10 code2) 3 differential diagnoses with ICD 10 code.3)Vital sign, BMI4)Complete Chief patient compliant5)Subjective Information6)PMH, PSH, FH, ROS completed. Provide complete and concise summary of pertinent information.7)Complete Objective Information8)Lab Tests9)Allergies10)Complete physical exam with critical elements related to subjective data.11)Perform Assessment12)Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.13)Create a Plan14)Plan includes pharmacologic and nonpharmacologic treatments as well as education provided. The plan is supported by evidence/guidelines, and the follow-up plans are noted.15)Self-Assessment & Clinical Guidelines16)Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.B) Discuss of Genital Herpes.Etiology, pathophysiology, sign and symptomps,Pharmacological and non-pharmacolgical treatments, education and prognosis.
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Name: F.K
eMedley Log
SUBJECTIVE
CC:
SOAP NOTE
Date: 06/16/2017
Age: 25 years
Time: 9:02
Sex:
Female
“I had a positive urine pregnancy test at home and I came to seek care for my pregnancy”
HPI:
F.K. is a 25 years old Hispanic female who presents to the GYN office today to seek prenatal care after
having a positive urine pregnancy test at home last week. Patient is calm, comfortable, and appears to be in
no acute distress. Patient reports missing menstrual period for 6 weeks and mild morning nausea and breast
tenderness for the last 3 weeks. Patient states she feels nauseated in the mornings after breakfast but nausea
goes away by itself. Patient denies vomiting, vaginal discharge, bleeding or any other symptoms. Patient
reports trying to conceive for the last 6 months after stopping oral contraceptives. Patient is G1P0 based on
results of home pregnancy test. Patient reports LMP 05/03/2017 and decides to do a pregnancy test last
week after missing her period for about 5 weeks. Patient reports regular menstrual periods every 28 days
lasting 4 to 5 days and using 3 to 4 tampons a day. Patient is sexually active and in a monogamous
relationship with her husband. Reports 2 lifetime sexual partner and denies sexually transmitted diseases
(STDs). Patient she is taking folic acid 400 mcg daily and multivitamins.
Patient provided the HPI as follows:
O – Onset of symptoms – Missing periods 6 weeks, nausea and breast tenderness 3 weeks.
L – Location of symptom – Uterus, digestive system, and breasts
D – Duration of symptom – Missing menstrual period constant for 6 weeks. Nausea intermittent, in the
morning for 3 weeks. Breast tenderness constant for 3 weeks.
C – Character of symptom – Breast are sensitive and feel swell. Nausea is mild occur after breakfast.
A – Aggravating/Alleviating Factors – Breast tenderness get worse whit touch and alleviate when wearing
a support bra.
R – Radiation of symptom (if pain) –None.
T – Timing of symptom – Nausea in the morning after breakfast. Missing periods and breast tenderness are
unchanged through the day and night.
T – Treatment received so far – None
S – Severity of symptom – Nausea and breast tenderness are mild. Patient relates those symptoms with the
missing period as signs of pregnancy.
Prenatal care is important for a healthy pregnancy to ensure maternal safety and to allow early fetal
assessment. Prenatal care should follow a holistic approach taking in consideration the physical, social, and
emotional needs of the pregnant woman (Schuiling& Likis, 2017). Prenatal care includes prenatal visits,
nutritional care, and education and patient patient-specific issues. The first prenatal visit should include a
comprehensive health history and physical examination, laboratory work including Pap smear and sexually
transmitted disease (STD) testing, and education about pregnancy health (Schuiling& Likis, 2017). The
Institute of Medicine (IOM) recommended guidelines to determine the expected weight gain during
pregnancy based on the body mass index (BMI) (IOM, 2009). Nutrition education should promote a wellbalanced and varied diet following patient’s food preferences with an increase of 350 to 450 calories per
day and including protein, carbohydrates, fats, and micronutrients (IOM, 2009). Daily prenatal vitamins
containing folic acid 400 micrograms and vitamins A, C, D, E, B6, B12, niacin, thiamin, riboflavin,
calcium, zinc, iodine, and iron are recommended as tolerated throughout pregnancy (IOM, 2009). The
American Academy Pediatrics (AAP), American Congress of Obstetricians and Gynecologists (ACOG),
and the March of Dimes recommend that prenatal care visits scheduled at proper intervals for testing and
screenings, monitoring normal pregnancy, and potential complications (AOCG, 2012).The AOCG
recommends screening for depression and psychosocial screening for all pregnant woman not only during
the first visit but during prenatal care to recognize patients at risk and initiated treatment and appropriate
referrals (ACOG, 2015; ACOG, 2006). The ACOG also recommends influenza vaccine for pregnant
woman during the influenza season and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis
(Tdap) vaccination during the third trimester (ACOG, 2013). During the first prenatal visit education
should be provided healthy behaviors, dental care, nutrition, wearing a seat belt, exercise, avoiding
substance and hazardous-chemical exposure and hot tubs or saunas, domestic violence exposure, sexual
activity, avoidance of alcohol, tobacco and recreational drugs among others (Schuiling& Likis, 2017).
Based on the above recommendations, the patient was given a complete physical exam including a pelvic
and a breast exam, a Pap smear, screening for STDs including Chlamydia and Gonorrhea, and education
and counseling about nutritional needs during pregnancy, vaccines, prenatal care and promotion of healthy
behaviors during pregnancy.
Medications: (list with reason for med )
Folic acid 400 mcg one tablet orally in the morning as a supplement
Multivitamins one tablet orally daily as a supplement.
PMH
Allergies: No known drug, food, latex, or environmental allergies
Medication Intolerances: None
Chronic Illnesses/Major traumas: Denies any chronic illness or trauma.
Hospitalizations/Surgeries: Denies any hospitalization or surgery
Immunizations: Admits receiving recommended vaccines and having immunization records uptoday
Family History (at least 3 generations)
Mother: 50 years old and healthy
Father: 50 years old with hypertension
Maternal GM 81 years old with diabetes
Maternal GF Deceased at age 70 leukemia
Paternal GM: 75 years old with hypertension
Paternal GF: 77 years old with hypertension and high cholesterol
Brother: 29 years old healthy
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, marijuana. Safety status
Education Level: Bachelors degree in Education.
Occupational history: Elementary school teacher. Works full-time Monday to Friday 40 hours a week.
Currently on vacation. She is a 10 months employee and school year ended last week. She will return to
work in the second or third week of August.
Current living situation: Married. Lives with husband in a rented apartment.
Substance use/abuse: Denies substance use/abuse.
ETOH: Denies use.
Tobacco Use: Non- smoker
Safety Status: States she always uses seat belt while driving and as a passenger. Home environment is safe
and free from physical hazards and emotional abuse.
ROS
General
Cardiovascular
Patient denies fatigue, fever, chills. Denies weight
change and night sweats. Denies lack of appetite.
Denies chest pain, palpitations, PND, orthopnea,
and edema.
Skin
Respiratory
Denies delayed healing, rashes, bruising, bleeding
or skin discolorations, any changes in lesions or
moles.
Denies cough, wheezing, hemoptysis, dyspnea,
pneumonia history, and TB history and contacts.
Eyes
Gastrointestinal
Denies use of corrective lenses. Denies blurring,
and visual changes of any kind
Patient reports morning nausea after breakfast that
goes away by itself for 3 weeks. Patient denies
vomiting, abdominal pain, diarrhea, constipation,
hepatitis, hemorrhoids, eating disorders, ulcers,
black tarry stools.
Ears
Genitourinary/Gynecological
Patient denies ear pain, hearing loss, ringing in ears,
discharge.
Denies any urgency, frequency, or change in color
of urine.
Sexually active at age 19. Two lifetime sexual
partners. Denies STDs or condom use. Us
Fe: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Last Pap: Pap smear 2015
Breast Self-Exam (BSE): Admits to performing
monthly BSE after menses.
Mammogram: Denies
Menstrual complaints: Missing menstrual period
for 6 weeks.
o
o
Menarche: 13 years old
Frequency of menstrual periods: Every 28
days.
o Length: 4-5 days.
o Menstrual flow: 3-4 tampons a day.
o Dysmenorrhea: Denies
o LPM: 05/03/2017
Vaginal discharge: Denies
Pregnancy history: G1P0. Based on results of
home urine pregnancy test.
Nose/Mouth/Throat
Musculoskeletal
Denies sinus problems, dysphagia, nose
bleeds/discharge, dental disease, hoarseness, or
throat pain
Breast
Denies back pain, joint swelling, stiffness or pain,
fracture history, osteoporosis.
Patient reports breast tenderness and swelling for 3
weeks. Denies lumps, or bumps. Admits BSE.
Denies syncope, seizures, transient paralysis,
weakness, paresthesias, black out spells.
Heme/Lymph/Endo
Psychiatric
Denies HIV status. Denies blood transfusion
history. Denies bruising, night sweats, swollen
glands, increase thirst, increase hunger, cold or heat
Denies anxiety, sleeping difficulties, suicidal
ideation/attempts, previous dx.
Neurological
intolerance.
OBJECTIVE (Document in the Inspection, Palpation, Percussion, Auscultation) format except on
Abdomen (IAPP)
Weight: 121lbs
BMI: 21.4
Temp: 98.8 F
BP: 112/69mmHg
Height: 5ft 3 inches
Pulse: 68 beats/min
Respirations: 16 breaths/min
General Appearance:
Patient F.K. is a healthy-appearing 25 years old Hispanic female in no acute distress. She is well developed
and well nourished. She is alert and oriented x 4, answers questions appropriately; cooperative during
interview. She is dressed in clean blue pants and a white top.
Skin
Patient’s skin is pale pink and appropriate to her Hispanic ethnicity, warm, dry, clean and intact. No rashes
or lesions noted.
HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. No tenderness at facial and
maxillary sinuses. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent.
Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink;
congested and boggy. No septal deviation. Neck: Supple. Full ROM; cervical lymphadenopathy present
and palpable; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra heart sounds, clicks, rubs or murmurs. Capillary refill less
than 2 seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs sounds present and clear to auscultation in all
fields bilaterally. No anterior or posterior crackles/wheezes.
Gastrointestinal
Abdomen appears flat and non-distended; BS active in all 4 quadrants per auscultation. No rebound
tenderness noted with percussion. Abdomen soft and non-tender to gentle palpation. No
hepatosplenomegaly.
Breast
Breasts are free from masses, tender to light touch, no discharge, no dimpling, wrinkling or discoloration of
the skin.
Genitourinary
Female:Bladder is non-distended; no CVA tenderness.
External genitalia reveal coarse pubic hair in normal distribution; skin color is consistent with general
pigmentation. No vulvar lesions noted. Well estrogenized.
A medium size speculum was inserted; vaginal walls are dark pink and well rugated; with thin vaginal
discharge, no lesions noted. Cervix soft, has smooth surface, dark pink with nulliparous cervical os. No
lesions or drainage observed. Pap obtained and swabs for cultures.
Bimanual examination: Cervix is soft, No CMT. Uterus is antevert, slightly increased in size and regular
shape, non tender. Bladder is not distended. No adnexal masses or tenderness. Ovaries are non-palpable.
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable. Gait normal.
Psychiatric
Alert and oriented. Dressed in clean blue pants and a white top. Maintains eye contact. Speech is soft,
though clear and of normal rate and cadence; answers questions appropriately. Denies depression or
anxiety.
Lab Tests
Dipstick urinalysis: Normal results
Whiff test: Negative for amines
Urine pregnancy test: Positive
Pending results for the following tests:
Complete blood count (CBC)
Blood type and Rh factor Antibody screen
Rubella titer
Hepatitis B surface antigen (HBsAg)
Varicella antibody screen
HIV testing
Syphilis testing using Venereal Disease Research Laboratory (VDRL)
Urinalysis and urine Culture
Chlamydia and gonorrhea testing
Pap smear
Special Tests
None
Diagnosis
Differential Diagnoses
o
Leiomyoma of uterus unspecified (d25.9). Uterine fibroids are abnormal growths of
smooth muscle in the uterus most frequent in women older than 30. Fibroids usually do
not cause symptoms or may present with pelvic pain or vaginal bleeding. Physical
examinations evidenced a firm and enlarged uterus with irregular shape (Cash & Glass,
2014). A uterine fibroid was suspected in this patient due to the enlarged uterus but is
being ruled out based on the health history and physical examination.
o
Unspecified ectopic pregnancy (O.009). Ectopic pregnancy occurs when a fertilized egg
implanted outside the uterus, can be life-threatening for the mother if not diagnosed and
treated early, and is diagnosed during the first trimester of pregnancy (Schuiling& Likis,
2017). The diagnosis was suspected in this patient based on her history of missing
menstrual period associated with breast tenderness and nausea and a positive pregnancy
test but is being ruled out because patient doesn’t report any pelvic pain and the physical
examination doesn’t evidenced the presence of a mass or tenderness in the adnexas which
are the most frequent site for implantation.
o
Hydatidiform mole, unspecified (O01.9). Hydatidiform mole is another differential
diagnosis and was suspected based on the history of missed menses and presumptive
signs of pregnancy but patients with molar also complaint of abdominal pain, vaginal
bleeding, severe nausea and vomiting, tachycardia and hypertension (Schuiling& Likis,
2017). Based on the health history and physical examination this diagnosis is ruled out.
Diagnosis
o
Encounter for supervision of normal first pregnancy, first trimester (Z34.01). Pregnancy
is suspected in any woman with amenorrhea. The diagnosis of pregnancy is based on data
from health history, physical examination, and laboratory work evidencing elevated
levels of human chorionic gonadotropin (hCG) hormone (Schuiling& Likis, 2017).
Changes in the breasts, fatigue, urinary frequency, and nausea and vomiting are common
symptoms reported by woman in addition to amenorrhea and are known as presumptive
signs of pregnancy (Schuiling& Likis, 2017). During physical examination will evidence
softening of the cervix and uterus, bluish discoloration of the vagina and cervix and
enlarged uterus which are known as probable signs of pregnancy (Schuiling& Likis,
2017). Lastly, positive signs of pregnancy are auscultation of the fetal heart rate and
visualization by ultrasound (Schuiling& Likis, 2017). This patient present with history of
missing menses for 6 weeks, complaints of morning nausea and breast tenderness, and a
positive urine pregnancy test and her physical examination evidenced a softened cervix
and enlarged uterus with regular shape. Based on the heath history, physical examination,
and lab we can establish the diagnosis of pregnancy.
o
Less than 8 weeks gestation of pregnancy (Z3A.01). Based on patient LMP 05/03/2017
the gestational age for this patient is 6 weeks and 2 days and her estimated date of birth
(EDB) using the using Nägle’s rule is 02/10/2018 (Schuiling& Likis, 2017).
Plan/Therapeutics
o Plan:
?
?
Further testing – None.
The goals of prenatal care are to improve pregnancy outcomes and prevent
complications during pregnancy (Schuiling& Likis, 2017).
?
?
Medication:
a. Prenatal vitamins: Take one tablet orally daily with meals. Prenatal
vitamins containing 400 mcg of folic acid and daily allowance of
vitamins are recommended to prevent neural tube defects and normal
development of the fetus (Schuiling& Likis, 2017).
Education:
a. Priorities for the first-visit teaching include ensuring the woman has
adequate resources, include general information on topics such as
nutrition, healthy behaviors, dental care, exercise, wearing a seat belt,
avoiding substance and hazardous-chemical exposure, hot tubs or
saunas, potential domestic violence exposure, and sexuality during
pregnancy (Schuiling& Likis, 2017).
b. Pregnancy requires an increase of 350 to 450 calories per day and a
well-balanced, varied, nutritional diet consistent with the patient’s food
preferences should be encourage consisting of three meals per day and
at least two snacks (IOM, 2009)
c. The meal plan should include protein, carbohydrates, fats, and
micronutrients and is individualized to the health, weight (BMI), and
all factors that can affect the pregnant woman and fetus. A diet rich in
folic acid, omega-3-rich fish or supplement, fruits, and vegetables,
fiber-rich carbohydrates, low-fat meat protein or vegetable-based
protein, monounsaturated fats, and micronutrients via food should be
encouraged (IOM, 2009)
d. Weight gain during pregnancy is based on the BMI. You have a BMI of
21.4 which is considered normal and should expect a weight gain of 25
to 35 pounds throughout the pregnancy (IOM, 2009)
e. Prenatal vitamin supplements containing recommended daily
allowances of folic acid and vitamins A, C, D, E, B6, B12, niacin,
thiamin, riboflavin, calcium, zinc, iodine, and iron are recommended
(IOM, 2009)
f. Encourage to avoid unpasteurized milk, soft cheeses, raw or
undercooked meat, poultry, and shellfish, prepackaged lunch meat, hot
dogs, meat spreads, raw or partially cooked eggs, unpasteurized juices,
unwashed fruits and vegetables, and raw alfalfa sprouts to reduce the
risk for infections that can harm both the pregnant woman and the fetus
(Schuiling& Likis, 2017).
g. Caffeine intake should be limited to 200 mg daily maximum or two
cups of coffee of 8 oz each (Schuiling& Likis, 2017).
Alcohol consumption is contraindicated in pregnancy (Schuiling&
Likis, 2017).
i. Vaccines are recommended during pregnancy: Influenza vaccine
should be received during influenza season and Tdap vaccine during
the third trimester between 27 to 36 weeks (AOCG, 2013)
j. Pregnancy-related discomforts are caused by the physiologic changes
of pregnancy such as nausea and vomiting, fatigue, breast tenderness,
constipation, and nasal stuffiness and congestion (Schuiling& Likis,
2017).
k. To decrease or avoid nausea and vomiting eat five to six small meals
throughout the day and avoid spicy or hot foods (Schuiling& Likis,
2017).
l. Fatigue is common pregnancy discomfort, frequent during the first
trimester, improve during the second and often return at the end of
pregnancy. To prevent or decrease fatigue balance activity and rest
period thorough the day (Schuiling& Likis, 2017).
m. Breast tenderness is a common during pregnancy caused by increased
levels of hormones preparing breast for lactation, wearing a properly
fitted, supportive bra would help relieve the discomfort (Schuiling&
Likis, 2017).
n. Constipation is common during pregnancy. Increase dietary fiber and
fluids or using bulk forming laxatives will help alleviating constipation
during pregnancy (Schuiling& Likis, 2017).
o. Nasal stuffiness and congestion can be treated with saline nose drops or
saline nasal spray and placing a humidifier in the bedroom at night to
add moisture to the air (Schuiling& Likis, 2017).
Non-medication treatments:
a. Benefits of breastfeeding, recommended as the best feeding method for
most infants (Zolotor & Carlough, 2014).
b. Air travel is generally safe for woman with uncomplicated pregnancies
until 36 weeks of gestation. Long trips either a flight or by car increase
the risk for deep vein thrombosis (DVT). To prevent DVT wear
compression stockings, move your legs frequently, and drink plenty of
fluids during your trip (Zolotor & Carlough, 2014).
c. Practice good oral hygiene and visit the dentist for prophylaxis and
dental care (Zolo …
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