Nursing Soap Note for Gonorrhea, Case Study Example

Chief complaint: Creamy while discharge.

History of present illness: – Ms. R V is a 22 year old African American female who presented with a history of having excessive creamy white discharge vaginally for about one month. This was not accompanied by itching or burning. However, she was experiencing intermittent pelvic pain in the region of her bladder, but no frequency in passing urine. Further, she has been sexually active for more than four years. During this time she has changed two boyfriends and presently has one sex partner.

R.V explained that she can remember always having a discharge, but this increased over the past three weeks with a distinctive odor and is creating some concern since she has changed sex partners within the past two months. Since then she has reduced the frequency of sexual contact,  because of painful sexual intercourse, but the condition is persisting. Apart from this medical concern she considers herself relatively healthy. Denies any back, chest, or neck pains; colds, coughing, fever, or chills.

Medications

OTC: – Tylenol prn

Allergies

No known allergies

Past medical History:-

R.V. said that she was born with a low birth weight, weighing less than 5pounds at birth. This was due to her mother being hypertensive and a drug addict. Growing up she was always smaller than the children her age and frequently had colds with intermittent fever. Often R.V had to use supplements to maintain a normal weight even though her appetite is good. Between the ages of 3-5 she was considered 30% shorter and  weighed 20% less than children in that age group.  However, when approaching puberty after being placed on a rigid nutrition program R.V’s height improved by 20% and weight comparatively 10%.

Past surgical history:-

R.V reported that at age 6 she was involved in a motor vehicle accident and sustained a fractured femur which was repaired surgically. She recalled being hospitalized for two weeks and in rehabilitation for about three months.

Personal social history:-

R.V graduated high school four years ago. Since then she attended a community college and obtained an associate degree in early childhood education. Presently, she works at a children day care center catering for children 3 -5 years old. R.V loves to party and admits that she likes visiting the night clubs when she is off duty. At age 16 her mother died and she was never introduced to a father, but she developed a loving family relationship with her other three siblings.

This 22 year old lives alone and has no children. However, she confessed to having two abortions one at age 14 when still in high school and at 20. Within the past two years he has not become pregnant. This is beginning to become a concern since this new boyfriend does not have any children and wants a child to strengthen the relationship.

Family history

Mother was hypertensive and died at age 51. Siblings are healthy with ages ranging from 24 – 28. They all have an average of one child. Maternal grandfather is alive at age 73 years old. He has a history of chronic obstructive pulmonary disease and still smokes tobacco and illicit drugs (marijuana).

Immunization:-

R.V obtained all vaccines as a child, but has no health insurance now. Therefore, she does not have a primary care neither visits doctors frequently.

Review of systems:-

General – mildly underweight; no recent weight changes or loss, no fever, fatigue, or weakness.

Skin: no eczema, discoloration, sores, itching or dryness.

Eyes:  Has had no vision checks in years. R.V believes that she has 20/20 vision. Sees perfectly to read in the dark and tolerates looking at the sun with no discomfort to the eyes.

Ears: Has had no earing check recently and denies any changes in hearing ability, recently; exudate from ears or tinnitus. No ear pressure disclosure.

Nose: R.V declared that she has broad noses that  looks funny, but that is her African heritage and she does not have cosmetic money for septum repairs if it is unacceptable love funny, but it was her African heritage. Furthere she denies any nasal congestion. However, when she is feeling cold a clear nasal discharge may be produced until the cold symptom subsides. She denies any nose occasional bleeding.

Throat: Denies soreness in throat, hoarseness, bleeding gums, dry mouth, swelling and pain.

Neck: No abnormalities reported. R.V denies swelling; pain or numbness.

Respiratory: R.V denies any wheezing, shortness of breath, asthmatic episodes or rales.

Cardiovascular: denies palpitations, edema, pain in the chest, difficulty breathing upon exertion. R.V reports normal heart rate and high blood pressure readings, which she takes regularly at the local Wal-Mart store as a precautionary measure since her mother died from complications of hypertension.

Gastrointestinal: R.V denies nausea, diarrhea, vomiting or constipation. She repots having a bowel movement every day or every other day from birth.

Endocrine: R.V denies any irregularity in menstrual flow, thyroid dysfunction or adrenal function

Objective Data:

T: 36.5 Celsius (oral), BP 110/ 65 P: 96, RR: 16, wt: 125lbs. height 5 ft

Generalized appearance. R.V appears healthy; well groomed; articulate, slender body; glowing appearance; dimpled smile with piercing eye contact.

Skin: Clean, clear, consistent, with no discolorations, rashes, acne or abnormality.

Head: Normocephalic, Atraumatic.

Ears: Tympanic membranes appeared gray, non-bulging with free mobility with no erythematous; ear canal patent bilaterally. A very small amount of cerumen was seen. no unusually discharge neither odor was observed.

Nose: Nares were observed to be patent bilaterally with no nasal discharge or odor. The mucosa was observed to be pink and moist; septum midline normal; no presence of oedema was detected edema above frontal or maxillary sinuses. Upon percussion of sinuses tenderness was observed.

Pharynx: Oral mucosa appeared pink, moist.  No erythema, exudate, or lesions was seen in the Posterior oropharynx. The Tonsillar pillars were 2+ without exudate and the uvula rose evenly; Gag reflex normal and no hoarseness observed.

Neck: Upon palpation non-tender was observed and no lymphadenopathy, masses or thyromegaly.

Cardiac: Heart beat evaluation revealed that it was regular and rhythmic with no murmurs; normal S1 and S2. Also, S3, S4 murmurs were not detected. Upon observation no peripheral edema, cyanosis or pallor were detected. Extremities were warm and fully perfused with capillary refill less than 2 seconds and carotid bruits none existent.

Respiratory: respirations were normal and regular without difficulty. Chest expansion was symmetrical with clear bilaterally auscultation. Rhonchi, rales, diminished breath sounds or wheezing were observed.

Abdominal: This abdomen appeared soft, non-distended, non-tender throughout the palpation with an exception of slight refraction over the fallopian tube region, which could be rated 2-4 intensity. No masses felt, spleen size normal, uterus not palpable and bowel sounds positive.GU: Not assessed.

Neuro: R.V’s gait expressed normal mobility. R.V was fully oriented to time and place.

Labs: glucose 105, Hemoglobin A1C 11.4, Triglycerides 409. Results for gonorrhea revealed, nucleic acid amplification tests (NAAT) positive; nucleic acid hybridization test (DNA probe test, molecular probe test), positive; Gonorrhea culture +++++. Urinalysis bacteria +++++++.

Assessment:

Primary diagnosis:  Gonorrhea (promiscuous sexually active young woman) Gonorrhea is a sexually transmitted disease caused by Neisseria gonorrhoeae. The characteristic symptoms are creamy white discharge in females, pelvic pain accompanied by itching and burning in the pelvic region. In females the infection could be asymptomatic until a severe pelvic condition emerges. In men after three days exposure to the organism there is usually frequency of urination, burning and pussy discharge from the urethral orifice (Lozano, 2012).  This diagnosis was selected as my primary because R.V is a sexually active young female who appears to be promiscuous. Besides, she complains of a persistent creamy white and s supporting positive nucleic acid amplification tests (NAAT).

Differential Diagnoses

1. Pelvic inflammatory Disease ( PID):

Pelvic inflammatory disease is also referred to as PID. It is a female disorder usually caused by an ascending gonococci infection, which has become asymptomatic or drug resistant. However, other conditions can precipitate this infection also. They include incomplete abortions and insertion of intrauterine contraceptive devices (Deguchi, Nakane, Yasuda & Maeda, 2010).

2. Chlamydia trachomatis infection

Chlamydia trachomatis is an obligate intracellular human pathogen that infects the human genitalia. It belongs to the gram negative species. In men it affects the urethra and can goes unnoticed for years, but symptoms include a creamy discharge with dysuria. In this latent stage the organism can be transmitted during sexual intercourse to a woman who then displays symptoms/signs of the infection. These are manifested as pelvic inflammatory disease (Unemo, Golparian, Syversen, Vestrheim & Moi, 2010).

3. Herpes Genitals

This is a genital infection occurring from the herpes simplex virus. There are two classifications of ther HSV; HSV -1 and HSV-2.  The condition manifests as eruptions on the labia or vestibule. They could become painful and very irritating. There is no cure for herpes genitalia, which is a sexually transmitted disease (Hollier, 2011).

Plan

• Abdominal – have patient further evaluated for culture and sensitivity testing for gonococci and commencement of drug therapy (antibiotics) (pharmacological interven tion). Many antibiotics and tetracyclines are no longer are effective in the treatment of gonorrhea (Walker, C., & Sweet, R. (2011).
• Sex education intervention therapy. Refer patient for counseling to a certified social worker for interactive discussion on sexual behavior and alternative approaches to conducting sexual activities.

Reflection notes

A comprehensive assessment of Ms. R.V’s condition was conducted according to the principles contained in the SOAP assessment protocol. However, while I am satisfied that this was a through objective assessment, perhaps, if an evaluation of at least one of her sex partners history could have been obtained ther would have been more profound data for presenting her case to the certified case manager.

References

Deguchi, T. Nakane, K. Yasuda, M., & Maeda S (2010). Emergence and spread of drug resistant Neisseria gonorrhoeae. J. Urol. 184 (3): 851–8

Hollier, L. (2011). Genital herpes. Clin Evid (Online). 1603. Retrieved on April, 18^th, 2014 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217751/

Lozano, R (2012). Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380 (9859): 2095–128

Unemo, M. Golparian, D. Syversen, G. Vestrheim, D., & Moi, H (2010). Two cases of verified clinical failures using internationally recommended first-line cefixime for gonorrhoea treatment, Norway, 2010. Euro Surveill. 15:19721.

Walker, C., & Sweet, R. (2011). Gonorrhea infection in women: prevalence, effects, screening, and management. Int J Womens Health. 3: 197–206.