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 Education: Encouraged patient to continue to use a backup form of birth control is OCs are missed. Reiterate the importance of taking this medication as directed and maintaining only one sexual partner. Oral contraceptives can cause DVTs. Do not smoke while taking OCs, as it increases the risk of DVT. Certain medications decrease the effectiveness of OCs. If you are placed on a new medication, ensure that interactions are checked. If you miss a dose, take that dose as soon as possible. If two doses are missed, take two pills immediately, then continue taking one pill daily. If this occurs, use a form of back up birth control for up to 7 days. The use of OCs do not prevent against the transmission of HIV, AIDS or other STDs. Begin self -breast exams on a monthly basis.
Follow-up: Will call patient with test results if abnormal. Otherwise, schedule annual Pap for next year.
ICD 10: N94.6; Z30.09
S: Follow up for severe menstrual cramps. LMP 12/15/17; occurs every 28-30 days. Days of flow: 3-5. Has missed one day of school every time she has a period. First menses age 13. Takes OCT Ibuprofen with no relief. Uses heat pad, helps a little with abdominal discomfort. Denies other symptoms such as vaginal discharge, dysuria, fever, or abdominal pain at times other than menstruation. Admits that she is sexual active with two life partners. Last sexual encounter was about a month or so ago. Uses condoms but not all the time. Has not had a pelvic exam not has been tested for STD, since her mother does not know that she has been sexually active and would
not like her mother to find out. Interested in birth control.
O: Vitals: Temp: 98.7, HR: 88, RR: 18, BP: 110/68; H: 5' 4, W: 113, BMI: 19.4; External: Tanner
5 pubic hair, normal genital development, no lesion. Internal: cervix- nulliparious, os closed,
pink with no lesions. Scant clear mucoid discharge. Bimanual: anteverted uterus, normal
size with no masses; adnexa- normal, non-tender.
A: 16-year-old female Caucasian female, sexually active, with marked dysmenorrhea, in need of
contraception. Parent not aware of sexual activity and patient prefers to keep it confidential today. Introduced oral contraceptive pills to patient and mother as a treatment for severe dysmenorrhea. Both mother and patient agreed to a 2-6 month trial of oral contraception along with high dose Ibuprofen.
Differential Diagnosis: Endometriosis & PID
P: Labs: Denied STD or pregnancy testing right now due to mother being present.
Medication: Ortho-Cyclen 28 day. Dis: 1 pack. Sig: 1 tab po qd. Refill: 2 and Ibuprofen 600 mg Dis: 30. Sig: 1 TAB PO TID for dysmenorrhea. Refill: 3.
Education: Educated on contraception usage. Informed contest signed. Encouraged condom use
when patient’s mother was not present in room.
Follow-up: 3 months ICD 10: N76.0
S: c/c “I have very bad smelling discharge from my vagina.” Patient stated that the discharge is thick white and has been ongoing for one week, heavier in the morning. Has not tried anything form of treatment thus far. Reports one regular sex partner (for a period of one year) and 7 lifetime partners. States does not always use condoms, but knows the importance of using them. LMP: 12/22/17. Last pap: Unknown. G2T1P1A0L1; Twins at 21 weeks via C-section due to complications with pregnancy. Denies any other symptoms pelvic cramping, dysuria, unusual vaginal itching or burning, or n/v.
O: Vitals: Temp: 99.1, BP: 128/64, HR: 81, RR: 19, W: 162, H: 5’10, BMI: 23.2. PELVIC: ext.
genitalia + vaginal walls pink, pubic hair scant and shaven, cervix intact, closed os, thick white foul smelling discharge noted in vaginal canal, lower pelvic tenderness on bimanual exam, uterus smooth and within normal limits, ovaries not palpable.
A: 28 year-old Hispanic female presented with one-week history of bad smelling thick, white discharge from vagina. DX: Bacterial Vaginosis.
Differential Diagnosis: Trichomoniasis, Gonorrhea, Chlamydia
P: Labs: Gonorrhea, Trichomoniasis, and Chlamydia culture- results pending Medication: Flagyl 500 mg bid for 1 week
Education: Take medication as prescribed. Do not drink any alcohol while taking this medication
because it can cause nausea and or vomiting. Abstinence from any sexual encounters until medication regimen is completed and symptoms have are gone. Do not douche. Increase fluid intake.
Follow-up: Will call with test results if positive and readjust medication if needed. If symptoms worsen, call office for appt.
ICD 10: N73.9
S: c/c “I feel pain in my hips and bladder. I have been noticing occasional blood in my urine especially after sex and sometimes it hurts to pee.” Patient stated that there is blood in her urine but denies urinary frequency and urgency. She also verbalized whitish yellowish discharge; denies any foul odor or fever. She is worried about her recent sex partner and sounds disturbed about possibly having a STD. She denies any contraceptives on her part and does not use condoms.
O: Vitals: BP: 113/59; HR: 67; RR: 18; Temp: 97.8; H: 5’3” W: 128lb; BMI 22.6. External
genitalia without erythema, lesions or masses. No inguinal adenopathy. Vaginal mucosa pink, cervical redness & swelling noted with whitish yellowish homogenous discharge but no fishy or
foul smelling odor, (+) chandelier sign (cervical motion tenderness). Cervix was friable upon swab sample collection and no visible discharge in the cervical os after collection. Uterus midline and no adnexal masses. Rectovaginal wall intact, without masses.
