CC: prenatal revisit- SOAP 2

S – “I would like STD testing”

SJ, a 22 y.o. Caucasian female, G-0, LMP 6/6/23, BC – Nuvaring, presents for STD testing. Believes her new BF is cheating on her and would like full STD screen. Has noticed a yellow, malodorous d/c. Denies itching, fever, pelvic or abd. pain. Has not been using condoms. Menses regular. Last coitus - ~5days ago. H/O Chlamydia in 2022 – both partners treated. Note: I am not repeatedly writing “pt. states” – no need for complete sentences. Every note should start with this information!!

O: Vital Signs: Wt:115 lbs Ht: 60 in. BMI: 22.5 BP:102/72 HR:78 RR18: T: 98.6 SPO2: 99% on RA. Constitutional: General Appearance: Well-appearing, well-groomed, bright affect. Appears stated age. Cooperative and answers questions appropriately. Skin: Warm, dry, intact. No unusual bruising or suspicious lesions or moles. HEENT: Head: normocephalic and atraumatic. Face: symmetric. Eyes: Sclera white, no discharge. Conjunctiva pink. Cardiovascular: Regular rate and rhythm, s1 and s2 present, no murmurs, rubs, or gallops. Respiratory: Lungs CTA bilaterally. No rhonchi, rales, or wheezes.

Breast exam deferred. Note: if no exam done, document that it was deferred. Abdomen: Abdomen soft, non-distended, and non-tender. No CVA tenderness. Pelvic Exam: Note: documentation is working from outside >>>in External Genitalia: Hair distribution of normal female pattern. Vulva, labia majora, labia minora, and introitus are pink and moist without lesions or erythema. Perineum without lesions. No inguinal lymphadenopathy. Vagina: Walls pink and moist, rugae present, no lesions/tears, no odor, moderate amount of yellow discharge in the vaginal canal. No prolapse noted. No cystocele or rectocele noted. Good tone. Cervix: Pink, smooth, mobile, without lesions, bleeding, or polyps. Yellow discharge present. (Sureswab collected at this time).. Uterine: Uterus small, anteverted, midline, mobile, soft, non-tender. Negative CMT (Note: CMT is documented with uterine exam as this is assessed with the bimanual) Adnexae: No adnexal enlargement, tenderness, or masses palpated bilaterally. Urine HCG-Negative Wet Prep: Clue Cells: Positive. pH: 6.0. Hyphae/spores: Negative. Whiff: Positive. Trich: Negative. If wet preps are not done at your clinical site, indicate that you would have done one! A: Bacterial Vaginosis, STD Screening P: Rx – Flagyl 500mg. 1 tab po BID x 7 days (Written in prescriptive language) -Sureswab Plus (tests for GC/CT, BV, Yeast and Trich), RPR, HIV, Hepatitis b +c, -Safe sex education, condoms given. Advised re: No ETOH

-Reviewed ACHES -ALWAYS document this with hormonal contraceptives -Will call with results and base further treatment on results -Call if have any fever, chills, nausea, vomiting, flank pain.