ALBANY STATE UNIVERSITY

COLLEGE OF SCIENCE AND HEALTH PROFESSIONS

FAMILY NURSE PRACTITIONER PROGRAM
Episodic Care Information Sheet
STUDENT NAME: Alexander Warren
PT. INITIALS: H.C.

RACE: AA

DATE: 04/09/2015
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 - grandfather
SH: 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.
OBJECTIVE
BP: 116/62

P:

68

R:

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 DIAGNOSIS
1. Trichomoniasis
1. 2. Candidiasis.
3. Gonorrhea

2.
3
ASSESSMENT
1. 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

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