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 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