SOAP NOTE
Name: SW Date: 4/18/19 Time: 11:00am
Age: 18 Sex: F
SUBJECTIVE
CC:
“Yellow vaginal discharge x 1 week”
HPI:
18-year-old female G0P0A0 presented to clinic c/o yellow vaginal discharge x 1 week. Pt states she has
seen thick yellow vaginal discharge on a daily basis for the past 6-7 days. Pt states she has had slight
burning with urination, but she hadn’t thought anything of it until I asked about it. Pt denies vaginal burning
or itching. Denies abdominal pain, but does not slight lower abdominal tenderness to palpation. Thick light
yellow discharge noted in vaginal canal and over cervix on examination. Pt states that her female partner
was tested and was positive for chlamydia. Last contact with partner was 3 weeks ago. Pt has no history of
medical conditions.
Medications:
None
PMH
Allergies:
NKA
Medication Intolerances:
None listed
Chronic Illnesses/Major traumas
None
Hospitalizations/Surgeries
None
Family History
Maternal grandmother, died age 60, homicide
Maternal grandfather, died age 72, suicide
Paternal grandmother, 82, CHF, HTN
Paternal grandfather, died age 56 from MI
Mother, 45, Healthy
This study source was downloaded by 100000851720696 from CourseHero.com on 06-21-2024 18:45:43 GMT -05:00
https://www.coursehero.com/file/48563104/NSG-6430-Week-5-SOAPdoc/
Name: SW Date: 4/18/19 Time: 11:00am
Age: 18 Sex: F
SUBJECTIVE
CC:
“Yellow vaginal discharge x 1 week”
HPI:
18-year-old female G0P0A0 presented to clinic c/o yellow vaginal discharge x 1 week. Pt states she has
seen thick yellow vaginal discharge on a daily basis for the past 6-7 days. Pt states she has had slight
burning with urination, but she hadn’t thought anything of it until I asked about it. Pt denies vaginal burning
or itching. Denies abdominal pain, but does not slight lower abdominal tenderness to palpation. Thick light
yellow discharge noted in vaginal canal and over cervix on examination. Pt states that her female partner
was tested and was positive for chlamydia. Last contact with partner was 3 weeks ago. Pt has no history of
medical conditions.
Medications:
None
PMH
Allergies:
NKA
Medication Intolerances:
None listed
Chronic Illnesses/Major traumas
None
Hospitalizations/Surgeries
None
Family History
Maternal grandmother, died age 60, homicide
Maternal grandfather, died age 72, suicide
Paternal grandmother, 82, CHF, HTN
Paternal grandfather, died age 56 from MI
Mother, 45, Healthy
This study source was downloaded by 100000851720696 from CourseHero.com on 06-21-2024 18:45:43 GMT -05:00
https://www.coursehero.com/file/48563104/NSG-6430-Week-5-SOAPdoc/
