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Pt initial: M, M Female/28 yrs old

C.C: Visited for pap smear and discussion of birth control.

Mentions pain during sexual intercourse and virginal discomfort at rest.

Complains of recent lack of energy

V/S WNL 162 pounds

DX N76.9

B96.89

N94.10

R53.82

Z30.011

Z12.4

Plan

For N76.9 Metronidazole 500mg PO 1tab BID for 7 days.

For N94.10 pt was given an appointment to come back for a pelvic ultrasound to address this issue.

For R53.82, ordered labs: Vit A 25-Hydroxy, Vit B12, CBC, Platelet, Differential, T3, T4, TSH (blood was

drawn)

For Z30.011, start Norgestim Eth Estrad Triphasic tablet 0.18/0.215/ 0.25 MG-35MCG, 1tab PO daily

28days

For Z12.4, Lab IGP Apt HPVrfx 16/1845-199344 done

Counselling provided for 30 mins

Next appo in 2 wks for pelvic ultrasound

Pls complete it by Saturday 11pm. Use the soap note template. Pls research enough