FNP 592 Week 6 Clinical Documentation Template

• FNP 592 Week 6 Clinical Documentation Template

Order ready-to-submit essays - 100% plagiarism-free guaranteed!

Note: Our papers are 100% human-written. 

Student Name and clinical course: __________________(FNP 592)

Client’s Initials*: AB

Age: 32

Race: Caucasian

Gender: Female

Date of Birth: January 1, 1992

Insurance: Medicare

Marital Status: Unmarried

Subjective:

CC: ”I was suffering a foul-odored vaginal discharge, itching, pain in the vagina, and itchy discharge that has been persisting after 1 week.”

HPI: Our female client is a 32-year-old Caucasian female who presents with a complaint of vaginal dryness, itching, and discharge of a milky white color during the past week. She also complains that she feels burning pain during intercourse. The pain does not radiate. She has not utilized any medication so far. The agony worsens during intercourse. At home, the final body temperature was 98 degrees. She is rated to be at 5/10 in pain.

Past Medical History:

• Medical problem list: Hypertension (Onset: 22 y/o)
• Preventative care: Up-to-date vaccinations. The latest influenza shot was administered in August 2022.

• Surgeries: Abortion (2022)

• Hospitalizations: None

• LMP: Regular menses

Allergies: none

Medications:

• Chlorothiazide: Oral medication, 125-500 mg/day, take one tablet daily in the afternoon.

Family History:

• Father, age 65, diabetes, hypertension
• Mother, age 63, diabetes
• Sister, age 28, diabetes
• Paternal Grandfather, age 96, diabetes, asthma
• Paternal Grandmother, age 94, hypertension, diabetes

Social History:

The patient is sexually active, having a number of partners, and has no condom use during sexual intercourse. The patient is an alcohol consumer. She enjoys clubbing and reading novels as her hobbies.

Other: N/A

ROS

General: Well-oriented woman in no noticeable distress. Complaints of chronic vaginal pain and itch in the vaginal area.

Eyes: Negative for vision changes or double and blurred vision, pain, redness, or excessive tearing. Denies blindness

Ears/Nose/Mouth/ Throat: Denies hearing problems. No changes in the throat. Denies any sinus pain or nosebleed, bloody gums, or a dry mouth. The last dental checkup took place two months ago.

Cardiovascular: Reports moderately high blood pressure but denies any heart issues.

Pulmonary: Denies any issues in breathing and has an average respiratory rate.

Genitourinary: An inflamed vagina with dysuria is observed. Fishy-smelling discharge was reported.

Musculoskeletal: Denies any muscular pain or swelling. Reports normal muscle reflexes.

Neurological: Denies headaches, dizziness, weakness, or nausea.

Endocrine: Reports low levels of circulating estrogen.

Lymphatic: Denies swelling or pain in the neck’s lymph nodes.

Allergic/Immunologic: None.

Objective

Vital Signs

 HR- 88

 BP- 140/88

 Temp- 99.5

 RR – 18

 SpO2- 98.5%

 Pain level- 6/10

 Height: 5 feet 2 inches

 Weight: 132

 BMI-24.1 (within normal range)

 Labs, radiology, or other pertinent studies: Wet mount (microscopically), whiff test, and PCR tests.

Physical Exam

HEENT: optical reflex. It was viewed through an otoscope. No perforation was observed.

Mild cerumen on both ears. No signs of infection, trauma, or discharge.

Cardiovascular: Mild high blood pressure. Normal heartbeat. No murmur.

Respiratory: Breathing sounds and tactile auscultation of fremitus are standard on both sides of the chest.

Gastrointestinal: A non-distended, globular abdomen free of scars, lesions, or pulsations.

Regular bowel sounds and regular auscultation of the aorta or renal arteries.

Genital/Pelvic: Erythematous mucosa and foul-smelling white discharge are reported. No lesions or ulcers.

Anteverted, mobile, and nontender uterus, the cervix is parous without any abnormality.

Musculoskeletal: Muscle soreness is nonexistent. Perfect deep tendon reflexes on both sides +2.

Endocrine: High levels of estrogen are observed.

Assessment

Differentials

1. Vaginitis: Gardnerella vaginalis is the most prevalent cause of vaginal discharge that causes vaginitis, cervicitis, salpingitis, and infertility. It is predominant in sexually active women. Vaginosis is characterized by the primary effects of inflammation, vaginal pain, and discharge (Muzny et al., 2019).
2. Trichomoniasis: Also, it is connected to vaginitis. It is a sexually transmitted disease and contributes greatly to the spread of HIV.
3. Desquamative Inflammatory Vaginitis (DIV): DIV results in discharge, irritation, and itch. It is nothing that is a product of bacteria or fungi. The condition will result in the vaginal flora not being normal, and the PH will be elevated (Rosalyn Elizabeth Maben-Feaster et al., 2020).

Diagnosis: Vaginitis

Plan

Diagnostics: One of the vaginal or cervical samples is collected. The wet mount test is performed under the microscope. The sialidase activity of vaginal fluid is sensitive and specific to Gram staining. DNA probing can also be done.

Treatment: Metronidazole (Flagyl) comes in the form of tablets (750mg/day over the course of seven days) to be administered orally or Metronidazole gel to be applied to the vaginal area by the patient. In addition, Clindamycin (Cleocin) cream, Clindamycin tablets 150-300mg/day (oral route), or capsules (which you insert in the vagina) can also be prescribed.

Education: The patient must not apply perfume or deodorant that is likely to irritate the affected area. The vagina should be informed that the only part that should be washed using warm water is the outside part. Wear only cotton or cotton-lined underwear and never tight pants and pantyhose, particularly in summer. In addition, protection in having sex, such as condoms, etc., limits sex partners, and avoids drugs and nicotine.

Follow-up: No follow-up will be required when the symptoms are resolved, but in case they reemerge, the doctor should be visited to be treated further. Correct directions and medication would assist you in that.