SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal lustful and affliction in my inferior abdomen.”
HPI:
Pt is a 30y/o AA womanly, who is a new enduring that has of-late moved to Miami. She strives composition today behind unsuccessful self-composition of vaginal lustful, enduring upon urination, and inferior abdominal affliction. She is solicitudeful for the influence of a vaginal or bladder contagion, or an STD. Pt denies broil. She reports the lustful and enduring after a while urination has been confer-upon for 3 weeks, and the abdominal affliction has been intermittent gone months ago. Pt has tried OTC products for the lustful, including Monistat and Vagisil. She denies any other urinary symptoms, including conjuncture or quantity. She describes the abdominal affliction as either hard or dowdy. The affliction raze goes as exalted as 8 out of 10 at times. 200mg of PO Advil PRN reduces the affliction to a 7/10. Pt denies any irritant factors for the affliction. Pt reports that she did set-out her menstrual cycle this dawning, but denies any other libeobjurgate other that not-difficult bleeding inauguration today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a latesting sexual interconnection, and denies any new sexual partners in the latest 90 days. She denies any new-fangled or chronicled notorious charybdis to STDs. She reports the use of condoms after a while perfect coital trial, as polite as this being her solely fashion of contraceptive. She reports typical monthly menstrual cycles that latest 3-4 days. She reports dysmenorrhea, which she as-well takes Advil for. She reports her latest PAP begrime was in 7/2016, was typical, and reports never having an abtypical PAP begrime product. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not choose it perfect day. Her nativity hx includes the influence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for affliction
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and tender grandparents after a whileout notorious medical issues; 1 tally and 3 other sisters outside notorious medical issues; No offspring.
Social History
Lives alone. Currently in a latesting sexual interconnection after a while one man. Works for DEFACS. Reports interrupted alcohol use, but denies tobacco or unfair garbage use.
ROS
General
Denies weight vary, tire, broil, duskiness sweats
Cardiovascular
Denies chest affliction and edema. Reports high palpitations that are characteristic by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or bark discolorations, any varys in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the high palpitations and is as-well characteristic by drinking water
Eyes
Denies regulative lenses, blurring, visual varys of any kind
Gastrointestinal
Abdominal affliction (see HPI) and Hx of GERD. Denies N/V/D, constipation, inclination varys
Ears
Denies Ear affliction, hearing detriment, unclouded in ears
Genitourinary/Gynecological
Reports enduring after a while urination, but denies quantity or conjuncture. Contraceptive and STD obstruction includes condoms after a while perfect coital occurrence. Current latesting sexual interconnection after a while one man. Denies notorious chronicled or new-fangled STD exposure. Latest PAP was 7/2016 and typical. Ordinary monthly menstrual cycle lasting 3-4 days.
Nose/Mouth/Throat
Denies sinus problems, dysphagia, nose bleeds or liberate
Musculoskeletal
Denies end affliction, articulation swelling, stiffness or affliction
Breast
Denies SBE
Neurological
Denies syncope, seizures, paralysis, weakness
Heme/Lymph/Endo
Denies bruising, duskiness sweats, stilted glands
Psychiatric
Denies depression, apprehension, quiescent difficulties
OBJECTIVE
Weight 140lb
Temp -97.7
BP 123/82
Height 5’4”
Pulse 74
Respiration 18
General Appearance
Healthy appearing adult womanly in no intelligent annoy. Alert and oriented; answers questions well.
Skin
Skin is typical pretense for ethnicity, irascible, dry, pure and uncorrupted. No rashes or lesions noted.
HEENT
Head is norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in good relit.
Cardiovascular
S1, S2 after a while ordinary objurgate and rhythm. No extra character sounds.
Respiratory
Symmetric chest walls. Respirations ordinary and easy; lungs unclouded to auscultation bilaterally.
Gastrointestinal
Abdomen flat; BS erratic in all 4 quadrants. Abdomen smooth, suprapubic tender. No hepatosplenomegaly.
Genitourinary
Suprapubic tenderness illustrious. Bark pretense typical for ethnicity. Irritation illustrious at labia majora, minora, and perineum. No ulcerated lesions illustrious. Lymph nodes not obvious. Vagina pink and lively outside lesions. Libeobjurgate minimal, thick, black red, no fragrance. Cervix pink outside lesions. No CMT. Uterus typical largeness, pattern, and mass.
Musculoskeletal
Full ROM seen in all 4 extremities as enduring moved encircling the exam compass.
Neurological
Speech clear. Good intonation. Posture build. Balance latesting; grade typical.
Psychiatric
Alert and oriented. Dressed in pure clothing. Maintains eye continuity. Answers questions well.
Lab Tests
Urinalysis – blood illustrious (pt. on menstrual end), but products privative for contagion
Urine culture testing unavailable
Wet prep - inconclusive
STD testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B & C
Special Tests- No ordered at this time.
Diagnosis
Differential Diagnoses
1-Bacterial Vaginosis (N76.0)
2- Malignant neoplasm of womanly genital organ, unspecified. (C57.9)
3-Gonococcal contagion, unspecified. (A54.9)
Diagnosis
o Urinary tract contagion, locality not certain. (N39.0) Candidiasis of vulva and vagina. (B37.3) unimportant to confer-uponing symptoms (Colgan & Williams, 2011) & (Hainer & Gibson, 2011).
Plan/Therapeutics
Plan:
Medication –
§ Terconazole gist 1 vaginal collision QHS for 7 days for Vulvovaginal Candidiasis;
§ Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days for UTI (Woo & Wynne, 2012)
Education –
§ Medications prescribed.
§ UTI and Candidiasis symptoms, causes, risks, composition, prevention. Reasons to strive emergent solicitude, including N/V, broil, or end pain.
§ STD risks and obstructions.
§ Ulcer obstruction, including commencement Protonix as prescribed, not expanded the recommended dose article of NSAIDs, and not commencement NSAIDs on an vacuity stomach.
Follow-up –
§ Pt gain be continuityed after a while products of STD studies.
§ Return to clinic when high the end for perfashion pap-begrime or if symptoms do not contravene after a while prescribed TX.
