Soap Note Week 8

SOAP NOTE Name: MR Date: 03/18/2020 Time: 09:00 Age:28 Sex: F SUBJECTIVE CC: “Painful blisters in the genitalia” HPI: Mrs. MR is a 28 years old female with a past medical history of mild intermittent asthma and GERD. Beginning 4 day ago, patient noticed a burning pain with itching located in the genitalia. Yesterday , she noticed a red rash with small blisters in the painful area associated with dysuria and moderate white vaginal discharge. Pt, denies fever, headeache, vaginal bleeding and inguinal adenopathy. Pt. applied ice to site with little to no pain relief. Pt. states that she had unprotected sex 10 days ago with a new partner that she meet 6 months ago. Partner do no not present similarly symptoms. LMP was one week ago. Pt. states that her menstrual periods are regular and without pain. Her first menarche was at age 12. She take contraceptives pills as contraceptive method since one year. Patient is P1G2A1 with normal vaginal delivery. Patient denies any previous history of genital herpes or any other STI. She take medication for asthma and GERD. Seasonal Allergies know. Medications Montelukast Sodium 10mg Oral Tablet 1 PO at bedtime Pantoprazole Sodium 40mg Tablet, 1 PO every day for stomach Femynor (Combined Oral Contraceptive Pill) PO daily. Patient started 03/2019 PMH Patient present a past medical history of mild intermittent asthma and GERD. Non previous history of STI. Menarche at age 12. Immunizations reviewed and current. Quadrivalent HPV vaccine administered at age 13. P1G2A1 with a normal vaginal delivery. Last Pap Smear in June /2017, Breast Examination was performed in the same day. Results were normal for both exams. Allergies: Seasonal Allergies Medication Intolerances: N/A Chronic Illnesses/Major traumas: Mild intermittent Asthma and GERD Hospitalizations/Surgeries: Pt. was hospitalized when she had her son 5 year ago. Had an appendicectomy at age 22. P1G2A1 with normal vaginal delivery. ........................................continued......................................