Select a patient that you examined during the last three weeks. With this patient in mind, address the following in a SOAP Note:
- Subjective: What details did the patient provide regarding her personal and medical history?
- Objective: What observations did you make during the physical assessment?
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What would you do differently in a similar patient evaluation?
Patient Information:
Chief Complaint
vaginal discharge and odor
History of Present Illness
21 yo presents with c/o vaginal discharge. she did have positive chlamydia on 1/5/17 and states that she and her partner were treated. She denies having intercourse since that time.. she has not had a TOC. describes discharge as being light and being present for 1 week. There is an odor but it is not a fishy odor.. She also wants to know if she is able to use represh products to prevent vaginal discharge. She denies any abdominal pain, fever
Review of Systems
Constitutional: Denies fevers chills
Gastrointestinal: Denies nausea vomiting diarrhea, abdominal pain
Genitourinary: Negative
Gynecological: see HPI
Neurologic: Negative
Psychiatric: Denies anxiety and depression
Physical Exam
Vitals & Measurements
HR: 77 (Peripheral) BP: 116/71
HT: 64.5 in WT: 175.8 lb BMI: 29.71
Gen.: Alert and oriented, not acute distress
Abdominal: Nontender nondistended, bowel sounds present, incisions clean dry and intact
Genitourinary:
Vagina: Scant white discharge in the posterior fornix
Cervix: Cervical mucus and Mirena IUD strings noted at the os
Neurologic: Alert and oriented
Assessment/Plan
1. Acute Chlamydia trachomatis infection of genitourinary site
GCC obtained. encouraged condoms consistently. no signs of PID.
****pt contacted and informed of positive Chlamydia results. pt informed that medication has been sent her pharmacy. pt informed that she was given 500mg dosage so this time she will take two pills PO at the same time. pt informed that her partner can go to the health department for treatment. pt informed that the third party needs to be treated as well. pt educated on the importance of all parties being treated to reduced exposure and reinfection. pt verbalized understanding, no further questions at this time.
99214 office outpatient visit 25 minutes (Charge), Quantity: 1, Acute Chlamydia trachomatis infection of genitourinary site | Vaginal discharge
2. Vaginal discharge
Affirm collected. treat per results.
