WOMEN’S HEALTH MINI SOAP NOTES

WOMEN’S HEALTH MINI SOAP NOTES ICD 10: N39.0 S: Burning and pain with urination for 3 three days. Stated that her urine looks cloudy and has a foul odor. Denies fever, nausea, vomiting, myalgia, flank pain, blood in urine, any vaginal discharge, and, vaginal/vulvar irritation. She is sexually active, has same partner for last 4 years. G1P1001, with normal vaginal delivery. Menarche age 11. Last menses one week ago; regular 4- 5 days. Tested for STD one year ago. Negative for Chlamydia and Gonorrhea. O: Vitals: BP: 125/85 Pulse: 70 RR: 16 Temp: 98.1 W: 156 H: 5’6 BMI: 25.2. Pelvic exam was normal. A: 24-year-old female presented with 3-day complaints of burning and pain with urination. Cloudy urine with foul smell. Differential Diagnosis: Bacterial vaginosis or STD P: Labs: Urine culture: pending Medication: Cipro 250 mg PO q12hr for 3 days Education: Adhere to medication regimen. Instructed on personal hygiene; wash the perineal area from front to back and wear only cotton underwear. Avoid sexual intercourse until medication regimen has been completed and you no longer have symptoms. Increase fluid intake. Follow-up: If symptoms worsen, come back to office. Will call with test results in 48 hours. ICD 10: Z01.419; Z30.09 S: Yearly OB exam and refill BC. LMP was 3 weeks ago. Last pap & STD test one year ago. Menarche age 13. Sexual active with one lifetime partner. Uses condoms 50% of the time. G0P0. O: Vitals: Temp: 98.8: BP- 110/67: HR: 68: H: 5’7; W 178; BMI: 27.9. Pelvic exam: No bladder tenderness upon palpation, no distention noted. External genitalia normal, no gross lesions or lacerations. Vagina shows healthy, pink mucosa, no gross lesions, white discharge noted. Cervix shows no lesions. Wet prep has normal results. A: 19-year-old female presented for yearly OB exam, which after reviewing the patient’s records, it is noted that this is appropriate. Patient is sexually active and on oral contraceptives, therefore pap was recommended. Patient has requested a refill on her oral contraceptives and has discussed her usage of back up birth control when she occasionally misses a dose of medication. No differential diagnosis P: Labs: Pap smear: Pending; Wet Prep: Normal Medication: Tri Sprintec, 1 pill PO daily, disp #1, 11 refills