soap note

Name: Y. U

Date: 11/21/2018

Time: 1100 AM

Age: 32 y/o

Sex: Female

SUBJECTIVE

HPI: Y.U is a 32-year-old White female, who came to the clinic today complaining of 2-week discharge from my vagina, thick, white, and seems heavier in the morning. Also she refers lower abdominal pain, and pain when having sex, patient denies fever.

Medications: No.

PMH: Denies

Allergies: Denies any allergies to food or medication

Medication Intolerances: Denies.

Major traumas: Denies any trauma

Hospitalizations: Denies hospitalizations

Surgeries: Denies

Family History

Mother: Alive, Asthma well controlled.

Father: Alive, HTN, CAD.

Brothers:2 Alive and Healthy

Children: 1 Healthy.

Social History:

Home type: house.

Marital status: Married

Religion: Denies.

Tattoos: no

Alcohol: Denies.

Drugs: Denies any Drugs consumption.

Smoker: Non-smoker

Exercise: 30- 45 minutes of walk 2 times a week

Travel: Denies.

Blood Transfusion: Denies

OBSTETRIC/GYNECOLOGICAL HISTORY: Married, Sexually active, Heterosexual, denies STI's, Menarche: at age of 10 regular cycle, G1T1P0A0L1, Birth Control: condom.

ROS

General

Denies any weight change in the last past 6 months denies weakness, fatigue report monthly. No distress noted at this moment, responding question in an appropriated mood. No exercise intolerance.

Cardiovascular

Patient denies chest pain and palpitation. No edema noticed no syncope, no orthopnea.

Skin

Warm and dry, skin is appropriated color for ethnicity.

Respiratory

Patient denies cough, dyspnea, wheezing or hemoptysis, no acute distress at this moment.

Eyes

Denies changes in vision, no blurred vision, no diplopia, no tearing, no scotomata, and no pain.

Gastrointestinal

No nauseas, no emesis, no dysphagia, no bowel habit changes, no melena, no constipation.

Ears

Denies ear pain, hearing loss, ringing in ears, discharge, pearly grey membranes.

Genitourinary/Gynecological

Denies dysuria, frequency or urgency. Denies blood in urine. No urinary urgency, no change in nature of urine. White and thick, vaginal discharge since 2 weeks ago. OBSTETRIC/GYNECOLOGICAL HISTORY: Single, sexually active, Heterosexual, denies STI's, Menarche: at age of 10. LMP: 10/25/2018. 28 for 4 days, regular cycle, G1T1P1A0L1. Sexually active, one partner.

Nose/Mouth/Throat

Denies difficulty in smelling, sinus problems, nose bleeds or discharge. Denies dysphagia, hoarseness, or throat pain.

Musculoskeletal

Denies cramps, joint stiffness, arthritis or gout, limitation of movement, history of musculoskeletal or disk diseases; denies any muscle or joint pain.

Breast

Denied nipple discharge, breast pain or change in the breast skin.

Neurological

Denies history of headaches, syncope, seizures, stroke, memory disorder or mood change. No weakness, paralysis, numbness/tingling, tremors or tics, involuntary movements, or coordination problems. No mental disorders or hallucinations.

Heme/Lymph/Endo

Denies easy bruising or bleeding. No history of anemia, blood transfusions or reactions. Denies exposure to toxic agents or radiation. / Denies heat or cold intolerance, excessive sweating, polydipsia, polyphagia, or polyuria. No history of diabetes, thyroid disease, or hormone replacement.

Psychiatric

Denies depression, memory changes. Denies suicides attempts or thoughts. No history of mental illness.

OBJECTIVE

Weight:  132 lbs.   

BMI: 22.7

Temp: 98.4 F

BP: 108/64 mm/Hg

Pain: 6/10

Height: 5’4’’

Pulse: 86 bpm

RR: 18 bpm

O2 Saturation: 99 % at Room air

General Appearance

Patient is a 32 y/o White female appearing of staged age; Alert and oriented; answers questions appropriately. No acute distress at this time. AAOX4, PERRLA; answers questions appropriately. Pain level: 4-5/10 on scale of pain.

Skin

General appearance is normal. Normal temperature, Hydrated, no rashes or lesions described. Intact, warm, moist, good turgor. Screening for skin cancer performed no precancerous skin lesion.

HEENT

Head normocephalic, atraumatic and without lesions; hair evenly distributed. Throat: Pharynx mildly erythematous, no exudates. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa edematous, clear rhinorrhea, moderate airway obstruction. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist.

Cardiovascular

No murmur, no rubs or gallop upon auscultation.

Capillary refill 2 seconds. Regular rhythm and rate with S1, S2 normal, no S3 or S4

No edema.

Respiratory

Symmetric chest wall. Lungs: bilateral mildly, lungs clear upon auscultation, no rales, and no wheezes. Breath sounds equal, no rubs. No respiratory distress noted at this time.

Gastrointestinal

Abdomen Soft, non-tender, BS normal in all 4 quadrants. No hepatosplenomegaly, mass, or herniation

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. No axillary nodes.

Genitourinary

Genitalia:

The bladder is non-distended; no CVA tenderness.

External genitalia reveal coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. Normally developed female genitalia. No perineal or perianal abnormalities are seen. No genital lesion or urethral discharges. No noted introitus discharge or irritation.

Speculum examination: A small speculum was inserted gently; The cervix is pink, intact, firm, closed. Thick and white discharge observed in the vaginal canal. Lower pelvic tenderness on bimanual exam, uterus within normal limits, ovaries not palpable.

Musculoskeletal

Steady gait, no limping or musculoskeletal deformities, or muscular atrophy. Thoracic and lumbar spine, normal. Full ROM in all 4 extremities, no joint stiffness.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; normal gait.

Reflexes 2+ bilaterally throughout.

CN II-XII intact.

Psychiatric

Good judgment. Alert and oriented. Dressed in clean skirt and blouse. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab /Tests/Screening/Intervention/Assessment:

Laboratory /Diagnostic Test Ordered:

Urine Pregnancy test: Negative

Gonorrhea, Trichomoniasis, and Chlamydia culture results: pending

Special Tests:  Not performed.

 Diagnosis

A56.2-Chlamydial infection of genitourinary tract, unspecified

Z01.41 Encounter for routine gynecological examination.

Differential Diagnostic:

1.-Chlamydia

2.-Gonorrhea

3.-Urethritis

Plan/Therapeutics & Education:

Plan:

1. - Notification is recommended for any partner with whom the patient has had sexual contact within 30 days of the onset of symptoms or 60 days if asymptomatic.

2.- Advise patient to avoid sexual intercourse during treatment and for 7 more days following the last day of antibiotic treatment.

Medication:

Azithromycin 1 g by mouth in a single dose.

Non-medication treatments and education

Patient will be instructed on:

1. Consider testing for other STD’s such as gonorrhea and trichomoniasis and inform the patient of the need for partner notification and treatment.

2. Notification for any partner with whom the patient has had sexual contact within 30 days of the onset of symptoms or 60 days if asymptomatic.

3. Stress importance of completing treatment regimen.

4. Advise patient to avoid sexual intercourse during treatment and for 7 more days following the last day of antibiotic treatment.

5. Have routine screening tests for chlamydia prior to beginning a new sexual relationship.

6. Use condoms with sexual activity.

7. Abstain from sexual activity until you and your partner(s) have completed your prescribed medication. Your health care provider is required to report this disease to the public health department. The health department may contact you.

8. Untreated chlamydia in females may lead to a condition called pelvic inflammatory disease (PID). PID is a leading cause of infertility, increased ectopic pregnancies, and chronic pelvic pain in women.

9. Follow Dr. Orders and in case of emergency please call 911 or come to nearest ER.

10. Importance to maintain Hand Hygiene, General Hygiene. Diet habits and life style modification Healthy diet, Normal calorie diet or fat, increased fiber and vegetables in diet. Increase physical activity.

 Evaluation of patient encounter:

Interview process went well, practitioner elaborated the plan of care with patient, and education about STD’s was provided and verbalized understanding.