15 Oct Vaginal Discharge ?I?ve had itching and discharge for a few days.? 32-year-old female reports thick white discharge and itching for 4 days. No new pa
week 7 rw soap
Vaginal Discharge
“I’ve had itching and discharge for a few days.”
32-year-old female reports thick white discharge and itching for 4 days. No new partners. No pelvic pain.
Erythematous vaginal mucosa, white curd-like discharge.
Plan: Treat for yeast infection with fluconazole 150 mg PO x1; educate on hygiene and probiotics.
ICD-10: B37.3 (Candidiasis of vulva and vagina)
CPT: 99213
SOAP Note _______ NU___:_________ Herzing University |
Name:_________________________ Typhon Encounter #: _____________________ Comprehensive:____Focused:____ |
CC: |
“I’m having hot flashes and mood swings.” |
|
HPI: |
· Onset (O): Began approximately one year ago. · Location (L): Generalized sensation of heat involving face, neck, and upper body. · Duration (D): Each episode lasts several minutes, occurring multiple times daily and at night. · Characteristics (C): Sudden intense warmth and sweating, followed by chills; associated with irritability and mood swings. · Aggravating/Associated Factors (A): Nighttime warmth, stress, caffeine, and alcohol. · Relieving Factors (R): Cooling environment, loose clothing, relaxation techniques. · Treatment Tried (T): None; no prior use of hormone therapy. · Summary (S): 51-year-old Black female with one year of menopause (12 months amenorrhea) reporting moderate vasomotor and mood symptoms, seeking non-hormonal management. |
|
PMH: |
· Hypertension, well-controlled on medication. · No history of thromboembolic disease, breast cancer, or psychiatric hospitalization. |
|
OBGYN History: |
· G3P3 (all full-term vaginal deliveries). · Menopausal: 12 months of amenorrhea. · No post-menopausal bleeding. · LMP: 12 months ago. |
|
ALLERGIES |
No known drug allergies (NKDA). |
|
MEDICATIONS |
Lisinopril 10 mg PO daily for hypertension. |
|
SH |
· Non-smoker, rarely drinks alcohol. · Denies illicit drug use. · Works as a manager; reports high occupational stress and caregiving burden. · Diet balanced but minimal exercise. · Lives independently. · Christian faith provides emotional resilience and support. · No current sexual activity; heterosexual. · Financially stable, insured. |
|
FH |
· Mother: Type 2 diabetes and hypertension. · Father: Hypertension. · No known family history of breast, ovarian, or endometrial cancer. |
|
HEALTH PROMOTION & MAINTENANCE |
· Mammogram: Up to date. · Colonoscopy: Up to date. · Needs zoster (shingles) vaccine per CDC (2025) recommendations. · Engages in minimal physical activity; counseled to increase to ≥150 minutes/week. · Balanced diet; advised on calcium/vitamin D supplementation. · Sees dentist and eye specialist annually. |
|
ROS (put N/A in sections not completed day of exam) |
Constitutional |
Reports night sweats and fatigue; denies fever, chills, or weight loss. |
Head |
No headache. |
|
Eyes |
No vision changes. |
|
Ears, Nose, Mouth, Throat |
No sore throat, tinnitus, or nasal congestion. |
|
Neck |
No thyroid tenderness or swelling. |
|
Cardiovascular/Peripheral Vascular |
Denies chest pain or palpitations. |
|
Respiratory |
Denies cough, dyspnea, or wheezing. |
|
Breast |
No pain, nipple discharge, or masses. |
|
Gastrointestinal |
No nausea, vomiting, constipation, or abdominal pain. |
|
Genitourinary |
No dysuria, frequency, or hematuria. |
|
Pelvis |
No pelvic pain or discharge. |
|
Musculoskeletal |
No joint pain or stiffness. |
|
Integumentary |
No rashes or lesions. |
|
Neurological |
No dizziness, weakness, or syncope. |
|
Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) |
Reports irritability and mood changes; denies suicidal ideation. |
|
Endocrine |
Denies polyuria, polydipsia, or heat/cold intolerance. |
|
Hematologic/Lymphatic |
No bruising or lymphadenopathy. |
|
Allergic/Immunologic |
NKDA. |
|
Other |
N/A |
VITALS: |
HR: 74 bpm |
RR: 16/min |
BP: 128/78 mmHg |
Temp: 98.1°F (36.7°C) |
SpO2%: 99% |
Ht: 165 cm |
Wt: 72 kg (158 lbs) |
BMI: 26.3 kg/m² |
|
Age: 51 years |
LMP: 12 months ago |
PAIN: 0/10 |
||
(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)
|
General Appearance |
Well-appearing, cooperative, no acute distress. |
||
Head |
Normocephalic, atraumatic. |
|||
Eyes |
PERRLA, no conjunctival injection or scleral icterus. |
|||
ENT, Mouth |
Oral mucosa moist, no lesions. |
|||
Neck |
Supple, no thyromegaly, no lymphadenopathy. |
|||
Cardiovascular/Peripheral Vascular |
Regular rate and rhythm, no murmurs or edema. |
|||
Respiratory |
Clear to auscultation bilaterally, normal effort. |
|||
Breast |
Deferred today (up to date mammogram). |
|||
Gastrointestinal |
Abdomen soft, non-tender, no hepatosplenomegaly. |
|||
Genitourinary Female |
||||
· External Exam |
Normal |
|||
· Internal Exam |
Deferred (no complaints). |
|||
Obstetric |
N/A (postmenopausal). |
|||
Musculoskeletal |
Full range of motion, no tenderness. |
|||
Integumentary |
Warm, dry, no rashes. |
|||
Neurological |
Alert and oriented ×3; cranial nerves II–XII intact. |
|||
Psychiatric |
Cooperative, mildly anxious affect, no psychosis. |
|||
Endocrine |
No thyromegaly or tremors. |
|||
Hematologic/Lymphatic |
No lymphadenopathy or pallor. |
A: ASSESSMENT AND DIAGNOSIS |
||
DIAGNOSIS |
ICD-10 CODES |
|
PRIORITIZE DIAGNOSIS |
1. Menopausal disorder |
N95.1 |
2. Sleep disturbance secondary to menopause |
G47.00 |
|
3. Mood disorder associated with menopause |
F32.A |
VISIT CODES |
CPT BILLING CODES |
99214 |
|
DIAGNOSTICS |
POC TESTING |
None performed today. |
|
TESTS REVIEWED |
None; recommended follow-up labs |
P: PLAN |
||
1. |
Diagnosis: Menopausal Disorder Diagnostics Ordered: · TSH and CBC to rule out thyroid dysfunction or anemia. · Lipid panel and fasting glucose for cardiovascular risk screening. Therapeutic: · Venlafaxine XR 37.5 mg PO daily, may increase to 75 mg after 4–6 weeks if tolerated. · Encourage non-pharmacologic strategies: cooling techniques, layered clothing, reduce caffeine/alcohol, exercise ≥150 minutes/week, mindfulness or yoga. Education: · Explained medication use and potential side effects (nausea, insomnia, BP elevation). · Reviewed non-hormonal vs. hormonal therapy options. · Discussed calcium (1,200 mg/day) and vitamin D (800–1,000 IU/day) intake and weight-bearing exercise. Consultation/Collaboration: · Refer to gynecology if symptoms persist or patient elects to consider hormone therapy later. |
|
2. |
Diagnosis: Sleep Disturbance Diagnostics Ordered: · PHQ-9 and Insomnia Severity Index (ISI) screening. Therapeutic: · Continue venlafaxine XR; optimize dosing. · Sleep hygiene: cool room, consistent bedtime, avoid caffeine/alcohol at night. · Consider Trazodone 25–50 mg PO HS PRN for short-term insomnia. Education: · Maintain dark, quiet sleeping environment and limit screen exposure. · Exercise earlier in the day. Consultation/Collaboration: · Behavioral health referral for Cognitive Behavioral Therapy for Insomnia (CBT-I) if persistent. |
|
3. |
Diagnosis: Mood Disorder Diagnostics Ordered: · PHQ-9 screening to monitor for depression. Therapeutic: · Continue venlafaxine XR; supportive counseling. · Encourage relaxation, journaling, and faith-based coping strategies. Education: · Discussed link between menopause, mood, and sleep. · Instructed to report any depressive or anxiety symptoms. Consultation/Collaboration: · Behavioral health referral if mood symptoms worsen or PHQ-9 ≥10. |
|
(Used for comprehensive exams) |
· Encourage aerobic exercise ≥150 minutes/week and weight-bearing exercise. · Diet: increase calcium, vitamin D, and whole grains. · Maintain up-to-date screenings (mammogram, colonoscopy). · Recommend shingles (zoster) vaccine. · Continue annual dental and eye exams. · Stress reduction: mindfulness, prayer, or counseling as culturally preferred. |
|
FOLLOW UP |
· Recheck in 6 weeks to evaluate medication tolerance and symptom improvement. · Review TSH, CBC, and lipid panel results once available. · Return sooner if symptoms worsen or new concerns arise. |
Our website has a team of professional writers who can help you write any of your homework. They will write your papers from scratch. We also have a team of editors just to make sure all papers are of HIGH QUALITY & PLAGIARISM FREE. To make an Order you only need to click Ask A Question and we will direct you to our Order Page at WriteDemy. Then fill Our Order Form with all your assignment instructions. Select your deadline and pay for your paper. You will get it few hours before your set deadline.
Fill in all the assignment paper details that are required in the order form with the standard information being the page count, deadline, academic level and type of paper. It is advisable to have this information at hand so that you can quickly fill in the necessary information needed in the form for the essay writer to be immediately assigned to your writing project. Make payment for the custom essay order to enable us to assign a suitable writer to your order. Payments are made through Paypal on a secured billing page. Finally, sit back and relax.