NRNNP 6552 Reproductive Health. Candida Albicans or Polycystic Ovarian Syndrome Focus 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?
The patient is a 30-year-old female who presents with complaints of vaginal itching and discharge for the past two weeks. She reports that the discharge is white and thick and has a slight odor. She also reports that she has been experiencing painful intercourse and lower abdominal pain for the past month. The patient reports that she has had similar symptoms in the past and has been diagnosed with a yeast infection. She denies any recent antibiotic use or new sexual partners. The patient also reports a history of irregular menstrual cycles and difficulty losing weight.
On physical examination, the patient appears uncomfortable but in no acute distress. Vital signs are within normal limits. On pelvic examination, there is erythema and edema of the vulva with a thick, white discharge in the vaginal vault. The cervix appears normal with no lesions or discharge. Bimanual examination reveals tenderness in the left adnexa without any palpable masses.
Candida albicans vulvovaginitis
Polycystic Ovarian Syndrome (PCOS)
The primary diagnosis is candida albicans vulvovaginitis based on the patient’s symptoms of vaginal itching, thick white discharge, and previous history of yeast infections.
Diagnostics and primary diagnosis:
Vaginal wet mount with KOH prep to confirm the diagnosis of candida albicans vulvovaginitis.
Pelvic ultrasound to evaluate the adnexa and rule out any ovarian masses that could be associated with PCOS.
Treatment and management:
Oral fluconazole 150 mg as a single dose or topical antifungal creams for 7-14 days for candida albicans vulvovaginitis.
A course of metronidazole or clindamycin for 7 days if bacterial vaginosis is confirmed.
A referral to a gynecologist for further evaluation and management of PCOS.
The patient should avoid using scented soaps or douching and wear loose-fitting clothing.
Probiotics such as Lactobacillus crispatus to promote a healthy vaginal microbiome and prevent recurrent infections.
A low glycemic index diet and regular exercise for PCOS management.
Follow up with the patient in 2 weeks to assess response to treatment.
Schedule a pelvic ultrasound in 4 weeks to re-evaluate the adnexa.
In a similar patient evaluation, I would consider asking more detailed questions regarding the patient’s menstrual history and screening for other sexually transmitted infections. I would also consider discussing the importance of safe sex practices with the patient.