NURS 6551 Practicum – Focused SOAP Note and Time Log

NURS 6551 Practicum – Focused SOAP Note and Time Log

NURS 6551 Practicum – Focused SOAP Note and Time Log

Assignment 1: Practicum – Journal Entry

Reflect on a patient who presented with a vaginal discharge during your Practicum Experience. Describe key signs and symptoms that were consistent with a sexually transmitted infection (STI) versus a non-STI related infection. If you diagnosed the patient with an STI, describe your experience in telling the patient that she had an STI, as well as the patient’s reaction to the diagnosis. Explain how the diagnosis might impact the patient’s life short-term and long-term. Include an explanation of the patient’s medical history, drug therapy and treatments, and follow-up care. If you did not have an opportunity to evaluate a patient with this background during the last four weeks, you may select a related case study from a reputable source or reflect on previous clinical experiences.

Assignment 1: Practicum – Journal Entry

Reflect on a patient who presented with endometriosis, ovarian cysts, or amenorrhea during your Practicum Experience. Describe the patient’s personal and medical history, drug therapy and treatments, and follow-up care. Then, explain how treatment modalities differ for endometriosis, ovarian cysts, and amenorrhea, as well as the implications of these differences when diagnosing and treating patients. If you did not have an opportunity to evaluate a patient with this background during the last five weeks, you may select a related case study from a reputable source or reflect on previous clinical experiences.

Assignment: Practicum – Journal Entry

Reflect on a patient who presented with a breast condition during your Practicum Experience. Describe the patient’s personal and medical history, drug therapy and treatments, and follow-up care. Then, explain your patient education strategies for patients with or at risk of breast conditions. Include a description of how you might teach patients to perform breast self-examinations. If you did not have an opportunity to evaluate a patient with this background during the last six weeks, you may select a related case study from a reputable source or reflect on previous clinical experiences.

NURS 6551 Practicum – Focused SOAP Note and Time Log

Assignment 1: Practicum – Focused SOAP Note and Time Log

Select a patient whom you examined during the last three weeks. With this patient in mind, address the following in a Focused SOAP Note:

• Subjective: What details did the patient provide regarding her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• Reflection notes: What would you do differently in a similar patient evaluation?

This NURS 6551 Practicum – Focused SOAP Note and Time Log Assignment is due. You will submit your Journal Entries (Weeks 4, 5, and 6), the Week 7 Focused SOAP Note, and your Practicum Time Log by Day 7 of Week 7 (this week).

NURS 6551 Practicum – Focused SOAP Note and Time Log

JOURNAL SAMPLE

PLEASE DO NOT USE THIS AND RE-WRITE IT. WRITE SOMETHING NEW PLEASE THIS IS A SCHOOL SAMPLE

Introduction

A common presentation seen by practitioners is a bacterial discharge with a foul-odor. Often times practitioners are able to determine a diagnosis based on the patient’s history and their presenting symptoms. Before prescribing antibiotics, practitioners should perform a thorough assessment and perform a physical examination, including vaginal exam, prior to determining a diagnosis and prescribing medications.

Patient Presentation

This week a patient presented to the office with complaints of a white-green, foul smelling vaginal discharge with some itching. The patient is a 29-year-old G1P1 patient who is also single currently. The patient reports that she has noticed the discharge for a few days and states it is a medium amount and has not seen any blood associated with it. She states that she has felt moderate, constant suprapubic pain that has not radiated anywhere. Patient attempted taking Motrin for the pain, but states she felt no relief and the pain intensified when she had bowel movements and had to bear down. Patient denied fever, dysuria, urinary frequency, or other pain. Patient had Mirena IUD placed 2 years ago after she delivered her baby and reports an irregular period occurring every 50-60 days that is very light with spotting. She reports this last happening 5 weeks ago. She also is due for her routine PAP smear. Currently, the patient reports she has an active sex life and has recently had a new partner. She reports that during intercourse, the condom broke roughly one month ago. She is concerned that she may have a sexually transmitted infection (STI) and worries about potty training on the toilet and transmitting it to her daughter.

Examination

The patient stated she was “not ready” for a genital examination at this visit, she would rather be diagnosed based on symptoms and given medications to “cure” her. After being explained the importance of the examination, she agreed to have it done, admitting she was embarrassed. On examination, her vital signs were stable and was afebrile. She had bowel sounds present in all four quadrants, it was soft, non-distended, and non-tender except for the suprapubic area but had no guarding. The pelvic examination showed that the uterus was a normal size with no masses.

During the vaginal examination, the unopened cervix was visualized and there was greenish, malodorous discharge coming from the os. The IUD strings were also visible from the os once the discharge was cleared. There was also a foreign body identified in the vaginal canal that appeared to be a piece of a tampon after it was removed with forceps.

Treatment

Treatment will be dependent on the examination findings and diagnosis. The cervix was swabbed and samples were sent to the lab. The cervical ox was cleaned with a chlorohexidine sponge. The patient was given a pregnancy test as the condom broke, despite the presence of the IUD, which was negative. The patient believes in holistic treatment options and would prefer to try essential oils and herbs to cure the infection before she puts any medication, even antibiotics, into her body. She stated that if in 3 days she is still having these symptoms, she will call back to have the prescription sent to a pharmacy she prefers.

The patient was educated on the importance of being treated as soon as possible and the risk of toxic shock syndrome and sepsis. Education on signs and symptoms of both toxic shock syndrome and sepsis were provided. The provider called in the prescription to the pharmacy and told the patient to pick it up that way, should her symptoms get worse, she has it available.

Impact of Diagnosis

The patient was mortified that there was a tampon found in her vaginal cavity. She was confused on how it could have gotten there, and why she would not have known that it was still there, especially since she has had sexual intercourse since she had last inserted a tampon. The patient stated that she uses natural cotton tampons and that there is no string attached to the tampon, so at times it can be difficult to remove, but she tries her best to ensure she has taken the entire tampon out.

Follow-up

The provider called the patient to see if she wanted to make another appointment and to see if she picked up the prescription. The patient did not answer the phone, nor did she call back this week. The practitioner stated that she calls in prescriptions and other medications after educating the patient, even if the patient refuses, just in case they change their mind at a later time and decide to take the medications, it is readily available to them. I feel this is smart as it not only covers the patient, but also the provider.

References

Ahmed, N. M. (2019). Effect of Nursing Intervention on Knowledge about Genital Hygienic Practices Regarding Vaginal Infection among Intrauterine Device Users and Non-Users. International Journal of Nursing Didactics,09(01), 01-11. doi:10.15520/ijnd.v9i01.2398

Bacon, J. (2018). Foreign Body, Vagina. emedicinehealth. Retrieved from

Kapoor, B., Kapoor, A., Shah, S., & Vora, N. (2016). Study Of Prevalence Of Various Disorders And Presenting Complaints In Patients Of Vaginal Discharge. Journal of Evolution of Medical and Dental Sciences,5(01), 87-91. doi:10.14260/jemds/2016/20

Nurs 6551: Primary Care of Women – Sample SOAP Note

SOAP Note Week 3

Date: xxxx

Name: TS          Age: 33          Gender: Female          Race: Caucasian

SUBJECTIVE

Chief Complaint: TS came to the clinic with complains of unusual bleeding and discharge, difficulty urinating, pain around vaginal area, pain during intercourse and abnormal pap results.

HPI: The patient presented with painful urination, vaginal discharge and coitus pain. She also noted an increase in vaginal bleeding, Pap tests taken have been abnormal and pelvic area has also been experiencing pain. This has been going on for two weeks, for which she has been using OTC Ibuprofen.

PMH:

Allergies: None

Current Medication: Ibuprofen 600mg BD.

Immunization: Up to date

Previous Routine Tests: A normal pap smear 6 months ago

Past Illnesses: Recurrent UTI.

Hospitalizations: None.

Pregnancy History: G0 P0 A0

Family History: Mother has Type 2 Diabetes, Father has Hypertension, No siblings;  She lives with husband who has Arthritis.

Social History: She is an occasional smoker and is a social drinker. She denies use of illicit drugs. She tries to stay active by doing Zumba dance during free times. She works as a Lyricist for a music company.

ROS:

Constitutional: The patient appears unwell and is worried that the symptoms are gradually increasing and it has even started to affect his day to day life because of the pain. She denies incidences of fever, diarrhea, nausea and weight gain or loss.

HEENT: No headache, head bruises or rashes. Hearing capability seems normal. Uses reading glasses.

Cardiovascular: Normal heart rate and denies any murmurs, gallops and clicks.

Respiratory: The chest rises and falls rhythmically with the patient not complaining of wheezing, and coughing.

Gastrointestinal: Denies diarrhea, abnormal bowel movements and pain in the abdomen.

Genitourinary: Complains of pain while urinating, painful coitus, pain in the pelvic area, vaginal discharge and abnormal bleeding. Patient denies hematuria, urgency and frequency in urination.

Musculoskeletal: The patient denies any pain in the muscles, back pain or pain in the joints.

Neurologic: The patient has no deformities with the balance and is sensitive to the stimuli.

Psychiatric: Denies insomnia, nightmares, suicidal thoughts and abnormal headache.

OBJECTIVE:

Constitutional: T 97.5F, BP 114/71, HR 77, RR 23, Ht 4” 5’, Wt 146lbs

General: The patient is well groomed and responds questions. She looks distressed.

Head: No deformities or poor hair growth observed.

Eyes: Sclera white, normal light sensitivity and no abnormal discharge, no redness

Ears: Bilaterally intact, TM intact, no discharge

Nose: Pink and Moist mucosa, no sneezing or excessive discharge or congestion, no polyps

Throat: No Inflammation, swelling or dislocation.

Mouth: Oral mucosa is pink and moist

Cardiovascular: RRR, no murmurs, clicks or gallops. S1 and S2 present, capillary refill <3 seconds.

Respiratory: Chest clear, no wheezing or rales

Gastrointestinal: No diarrhea or constipation; generalized tenderness; bowel sounds present in all 4 quadrants.

Genitourinary: Painful urination, painful coitus, pain in the pelvic area, vaginal discharge and abnormal bleeding, no hematuria, urgency and frequency in urination.

Musculoskeletal: Normal gait, no muscular tenderness or swelling

Neurologic: The patient has normal gait, responds effectively to all temperature extremes.

Psychiatric: No insomnia, nightmares, suicidal thoughts.

Labs: Pap smear, endometrial biopsy, Curettage and dilation, transvaginal ultrasound and Computed tomography.

ASSESSMENT

Diagnosis:  Endometrial cancer

Endometrial cancer: This refers to a type of cancer that majorly affects the uterine lining makes the cells to grow abnormally to the point where they can affect other body parts (Shafer & Van Le, 2013). During early onset of the condition, there will be excessive vaginal bleeding that does not have a relationship with menstrual periods. The other symptoms include painful sex, pain while urinating, vaginal discharge and painful pelvic area (Kulkarni & Harshavardhan, 2017). The Pap smear showed abnormal results of glandular cells that are abnormal. All the other tests were positive for endometrial cancer.

Endometrial Hyperplasia: Common presentation is abnormal uterine bleeding. In premenopausal women, the symptoms include irregular heavy menstruation or amenorrhea in some cases. Endometrial biopsy differentiates endometrial hyperplasia from cancer. However there in 42.6% cases of endometrial cancer, the initial diagnosis was hyperlasia with atapia (Endometrial Cancer, 2018).

Endometriosis: Symptoms include pain, dyspareunia and painful defecation. It is common in young premenopausal women. Physical examination reveals tenderness and nodularity. Pelvic ultrasound can be done to confirm endometrioma (Endometrial Cancer, 2018).

PLAN:

The ideal treatment for this cancer is through surgery where the tumor will be removed (Shafer & Van Le, 2013). Additionally, some of the healthy tissues that surround the tumor will be removed since they could be containing some cancer cells. Simple Hysterectomy will be ideal for the patient due to the extent of the spread of the cells (Eifel, 2015).  In this case, the cervix and uterus will be removed since the cancer cells have not spread so much to the other parts of the reproductive system.

The patient will have to keep visiting the health facility after the procedure for routine maintenance and test to ascertain that the tumor does not regenerate.

Reflection notes:

In this case, the diagnosis itself is a big shock to the patient. Also, the pain suffered by TS is limiting her from his daily activities. Ignoring these could attribute to mood disorders or depression. She should be introduced to support groups with people going through the same diagnosis. This will also help her overcome the mental and physical pain caused by the disease. NURS 6551 Practicum – Focused SOAP Note and Time Log.

References

Eifel, P. J. (2015). Treatment of Endometrial Cancer. Pelvic Cancer Surgery, 315-325. doi:10.1007/978-1-4471-4258-4_30

Endometrial cancer. (n.d.). Retrieved March 18, 2018, from

 

Kulkarni, Y., & Harshavardhan. (2017). Recurrent Endometrial Cancer. Current Concepts in Endometrial Cancer, 107-116. doi:10.1007/978-981-10-3108-3_9. NURS 6551 Practicum – Focused SOAP Note and Time Log.

Shafer, A., & Van Le, L. (2013). Endometrial Hyperplasia and Endometrial Cancer. Gynecological Cancer Management, 53-66. doi:10.1002/9781444307542.ch5.