SOAP Note ExampleXX, 27yowf, NKDA CC: “ I have very bad smelling discharge from my vagina. ” S: HPI: 27 yowf. Setting: health department, hx per pt. Hx: 3w “bad smelling dischargefrom my vagina”, “thick, white, and seems heavier in the morning”, no aggravating or reliving factors noted. Social hx: Lives c boyfriend + 1 child in single home, not working, denies anyexposure to smoke at home and denies smoking. Reports 1 regular sex partner and 7lifetime partners. States does not always use condoms, but knows the importance of using one. Med hx : + for 1 (2006) c-section delivery of twins, dx of Chlamydia in March 2012, May2006, and June 2008, and dx of Gonorrhea in May 2007. Fam hx: + for HTN and Thyroid CA. Diet/Exercise : jogging 3x/wk, states “I try to eat healthy stuff when I have time”. Pregnancy hx: G2T1P1A0L1 – Twins at 21 weeks via C-section due to complicationswith pregnancy Menstrual hx : LMP “two weeks ago” c “heavy but normal” flow x5 -7d, no bleeding/spotting since then, last PAP “unknown”, no previous mammo ROS: Denies HA, neck/back pain, abd pain, muscle weakness/pain, malaise, pelviccramping, dysuria, s in bowel or bladder habits, breast tenderness, nipple darkening,unusual vaginal itching or burning, or n/v Current Meds: BC Patch: Ortho Evra (0.02mg/0.15mg)/24 hours – apply to skin eachweek x 3 weeks, then off one week (days 22-28), and repeat cycle O: Height not taken, 108lbs, 128/64, temp not taken, pulse not taken, 20 Exam: Well-nourished, A&Ox3, skin PWD, head normocephalic, eyes and ears notexamined due to time constraints, thyroid not enlarged, lungs CTA, CVRRR,cervical/axillary lymph nodes non-palpable, bilat breasts non-tender to palp, areolaslight pink, no palpable nodes, abd S/NT, BS not auscultated due to time constraints,adequate muscle tone + full AROM x4, no edema noted, cap refill <2sec, PELVIC : extgenitalia + vaginal walls pink, pubic hair scant and shaven, cervix intact, closed os, thickwhite foul smelling discharge noted in vaginal canal, lower pelvic tenderness onbimanual exam, uterus smooth and within normal limits, ovaries not palpable LABS : Gonorrhea, Trichomoniasis, and Chlamydia culture – results pending A:Dx: Bacterial Vaginosis Diff. Dx: Trichomoniasis, Gonorrhea, Chlamydia P:Medication: Flagyl 500 mg bid for 1 week for Bacterial Vaginosis
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