NR 602 Week 4 SOAP_Lataille_2020 – Chamberlain College of Nursing | NR602 Week 4 SOAP_Lataille_2020

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NR 602 Week 4 SOAP_Lataille_2020 – Chamberlain College of Nursing K.F., 38yo, F, Caucasian and Latino S. CC- fatigue, right breast pain, vaginal itching HPI- The breast pain is in the... right breast and now into the right axilla. It is warm and tender to touch. She has not noticed any nipple discharge. She has also had mild myalgia. The vaginal itching began a few days before the breast pain. She reports a great deal of stress. She has not been monitoring for a fever. She denies diarrhea or constipation, abdominal pain, skin changes, cough, or chest pain. She has not been sleeping well, due to having to stay with her daughter in the hospital. No recent physical or well woman exam since the birth of her son. She has not had dysuria. LNMP was 6 weeks ago, 8 days in length, heavy for 5 days with clots.  Menses are irregular, having only 5 to 6 per year. PMH- No surgical history other than cesarean sections; no trauma history; 10 year 1PPD smoker, smoking cessation 2 years ago; gestational diabetes with last pregnancy; history of PCOS. Gravidity and Parity: G:4, T:2, P:1, A:1, L:3. - - - - - - - - - - - - - - - - - - - - - Allergies- NKA O. Vital Signs: Height: 160cm Weight: 70 kg, B/P:120/62, T: 99.2, HR: 100, Resp: 16, reg, non-labored, SpO2: 99%. BMI: 27.34 (Overweight) General: Awake, alert, appropriate; well groomed; skin: warm, dry, intact. HEENT: Head normocephalic. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; neck supple w/o lymphadenopathy. Breast Exam: Tanner IV female with large pendulous breasts bil. No nipple discharge. No nodules. Tenderness and erythema in a 6cm oval area to the right breast in the upper outer quadrant and into the tail of Spence. Right axilla lymphadenopathy noted. Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen, soft, with normoactive bowel sounds throughout. Abdomen: Normoactive bowel sounds throughout; tenderness to palpation in the super-pubic area; no masses or organomegally; peripheral pulses reg., equal, intact; pelvic exam reveals sl. injected vaginal mucosa with a moderate whitish discharge. Erythema to the inside of the labia minora also noted. Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, positive WBCs, nitrites, and leukoesterase; negative for RBCs, glucose, and ketones. Wet mount: Positive for Spores, Hyphae and clue cells. A. Primary Diagnosis: Mastitis (91.22)- Mastitis is a swelling of the breast that is usually caused by an infection. Women with mastitis may have pain with a tender, red, wedge-shaped area on the breast. They may also have fever and chills, or they may feel tired and sick (AFP, 2016). Kayla is having right breast tenderness that is now spreading to the axilla.  - - - - - - - - - - - - - - - - - - - - - - - - - - Risk factors for vulvovaginal candidiasis include vaginal or systemic antibiotic use, diet high in refined sugars, and uncontrolled diabetes mellitus (Hainer & Gibson, 2011). Do not drink alcohol while on Flagyl it can cause severe abdominal pain, nausea and vomiting. Avoid alcoholic beverage for 24 hours after finishing the medication (Schuiling & Likis, 2013). The vaginal cream is oil-based and might weaken latex condoms and diaphragms. It would be best to refrain from sexual intercourse until both infections are cleared up (Hainer & Gibson, 2011). Kayla has ASCUS which stands for atypical cell of undetermined significance, she has abnormal cervical cells. With this result the provider should next check for the presents of the virus human papillomavirus (HPV) (Fontaine, Saslow, & King, 2012). Kayla also needs education on how HPV is contracted and what this means for her. Human papillomaviruses (HPV) is one of the most common sexually transmitted infections and is responsible for nearly all cases of cervical cancer. The HPV infection can be divided into low-risk (causing genital warts) and high-risk (causing cervical dysplasia, cervical cancer and other cancers). Risk factors for persistent infection include multiple sexual partners, sex at a young age, history of STI's, and smoking. Condom use is only partially protective against the spread of HPV (Jucktee & Hartman-Adams, 2010). Follow-up plan Follow-up typically is not required. However, women in whom symptoms persist or recur after treatment of initial symptoms should be instructed to return for follow-up visits. (CDC, 2015) References American Family Physician, 2016. Mastitis. American Family Physician, 78(6):732. CDC. (2015). Vulvovaginal Candidiasis. Retrieved from http://www.cdc.gov/std/tg2015/candidiasis.htm Epocrates. (2015). Trimethoprim/sulfamethoxazole. Retrieved from https://online.epocrates.com/rxmain Fenstermacher, K. & Hundson, B. T. (2016). Practice Guidelines for Family Nurse Practitioners (4th ed.). St. Louis, MO: Elsevier. Fontaine, P. L., Saslow, D., & King, V. J. (2012, September 15). ACS/ASCCP/ASCP guidelines for the early detection of cervical cancer. American Family Physician, 86(6), 501-508. Goroll, A. H. & Mulley, A. G. (2014). Primary Care Medicine (7th ed.). Wolters Kluwer Health. Hainer, B. L. & Gibson, M. V. (2011, April 1). Vaginitis: diagnosis and treatment. American Family Physician, 83(7), 807-815. Jucktee, G. & Hartman-Adams, H. (2010, November 15). Human papillomavirus: clinical manifestations and prevention. American Family Physician, 82(10), 1209-1214. Schuiling, K. & Likis, F. (2013). Women's gynecologic health (Second ed.). Burlington, MA: Jones & Bartlett Learning, LLC. [Show More]

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