Episodic Care Information
ALBANY STATE UNIVERSITY COLLEGE OF SCIENCE AND HEALTH
PROFESSIONSFAMILY NURSE PRACTITIONER PROGRAMEpisodic Care
Information Sheet
STUDENT NAME: Alexander WarrenDATE: 04/09/2015
PT. INITIALS: H.C.
RACE: AA
AGE: 21
SEX: F
ENCOUNTER DATE: 04/02/2015
SUBJECTIVE Chief complaint/concern: Pt comes in today
complaining of vaginal itching, burning, with a white discharge
that is foul smelling.HPI: Pt states that for about a week she has
had vaginal itching, burning, and soreness with a foul smelling
white discharge. She also complains of dyspareunia. She states she
has never had symptoms like this before. She states that the
symptoms have gotten progressively worse.PMH: Pt is otherwise
healthy. She has one child that was birthed vaginally with no
complications. Her yearly physicals are up to date. FH: Significant
for hypertension, diabetes, hyperlipidemia father. CHF -
grandfatherSH: Pt is a secretary at the hospital. Single with one
child. Patient denies alcohol or drug use. She states she has
gotten a new boyfriend over the last month. This is not the father
of her child. The father of the child is not in her or the childs
life. She complains of issues with money and how the father does
not pay child support.ROS:
Cardiovascular: Pt denies any chest pain, palpitations, or
extremity edema.Respiratory: Pt denies any SOB or cough.
Gastro: Pt denies any constipation, abdominal pain, diarrhea,
nausea, or vomiting.
Genitourinary: Pt denies any dysuria, foul smelling urine, or
cloudy urine.Reproductive: Pt complains of a burning sensation in
her genitalia with a foul smelling white discharge. She denies any
bleeding and she is due to begin her period in two weeks. She
denies any chance of her being pregnant. She is compliant with her
BCP and states her last period was 10-14 days ago.
OBJECTIVEBP: 116/62 P: 68R: 16 TEMP: 98.2 HT: 62 WT: 138 BMI:
25.2
Pertinent Physical Exam:Patient appears to be in no distress.
Genitalia exam reveals foul smelling, thin, white discharge. Labia
are slightly red and sore to touch. No bleeding noted. Swab
obtained with no problems.Lab Findings/Diagnostics: Wet prep
revealed trichomoniasis. DIFFERENTIAL DIAGNOSIS1.
2.
3ASSESSMENT1. Trichomoniasis. PLAN 1. Metronidazole 2 g orally
daily for 5 days. Patient given prescription for partner also.2.
Treat patient and partner to prevent reoccurrence. 3. Patient given
slip to take to lab to get tested for other STDs.4. Discussed used
of condoms and to always practice safe sex.5. Follow up with
regular yearly exams unless patient has other problems or concerns.
HEALTH PROMOTION ISSUES: Counseling: Safe sex, including risks of
STDs. Get yearly physical including eye screen. Wear safety belt
when riding in a car. Proper fit of car seat for children.
Screening: Continue yearly Pap smears and breast
exams.Immunizations: Instructed on importance of Tdap, patient does
not remember the last time she had one. Chemoprophylaxis:
Multivitamin.COMMENTS: Assignment Accepted
Please Re-Do
Faculty Initials: _________
Trichomoniasis
Candidiasis.
Gonorrhea
