SOAPnoteweek7.docx
For this Focused Note Assignment
you will select a patient with gynecologic conditions from your clinical experience and construct a patient history, assess, and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.
Basic patient information
40 y/o G2T2P0A0 present at the office, reporting vaginal itchiness and white vaginal discharge since a week ago. Pt expressed desire to get tested for STDs
PE: + White, stick discharge with external vaginal redness.
Plan
NuSwab collected.
STDs testing ordered
Diflucan 150mg 1 tab PO
A healthy diet low in sugars is encouraged.
Increase daily exercise.
Increase hydration
S/sex precautions reviewed.
RTO 2 weeks for results
No personal or family history of diabetes mellitus.
No stress
Not hx. of antibiotic use in las month.
Sexual partner stable for las 10 years.
Weigh 160 poundsheight 5’2”
The SOAP note must be completed. Using the attached template
Candidiasis as main diagnostic, include C. Albicans as first possible pathogen. It is more frequent, but differential must be done with other candida species and another STDs.
Please Explaining NuSwab test wisely. Include other like wet mountain, and KOH as differential diagnostic lab.
Treatment explanation should be based on ACOG guidelines.
On the management plant include.
Therapeutic interventions:
Diflucan 150mg 1 tab PO
Include probiotics use and doses.
Patient Education, Consultations and Referral, Health Promotions, Disease, Prevention, Disposition F/U, and a final Reflection about the lesson learned from the case.
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