soap 1


 
Select a unrepining that you examined during the decisive three weeks. Delay this unrepining in spirit, address the subjoined in a SOAP Note:
  • Subjective: What details did the unrepining yield respecting her singular and medical fact?
  • Objective: What observations did you establish during the visible rate?
  • Assessment: What were your differential diagnoses? Yield a insufficiency of three feasible diagnoses. List them from prominent guidance to lowest guidance. What was your important idiosyncrasy and why?
  • Plan: What was your delineation for diagnostics and important idiosyncrasy? What was your delineation for tenor and conduct, including choice therapies? Include pharmacologic and nonpharmacologic tenors, choice therapies, and follow-up parameters, as courteous-mannered-mannered as a rationale for this tenor and conduct delineation.
  • Reflection notes: What would you do differently in a resembling unrepining evaluation?

Patient Information:

Chief Complaint

vaginal execute and perfume
 
History of Confer-upon Illness
21 yo confer-upons delay c/o vaginal execute. she did possess substantial chlamydia  on 1/5/17 and states that she and her companion were manageed. She denies having dealing since that space.. she has not had a TOC. describes execute as substance unconsidered and substance confer-upon for 1 week. There is an perfume but it is not a fishy perfume.. She as-courteous wants to comprehend if she is effectual to use represh products to obviate vaginal execute. She denies any abdominal trouble, fever
 
Review of Systems
Constitutional: Denies fevers chills
 Gastrointestinal: Denies qualm vomiting diarrhea, abdominal trouble
 Genitourinary: Negative
 Gynecological: see HPI
 Neurologic: Negative
 Psychiatric: Denies solicitude and depression
 
Physical Exam
Vitals & Measurements
HR: 77 (Peripheral)  BP: 116/71
HT: 64.5 in  WT: 175.8 lb  BMI: 29.71
  
 Gen.: Alert and oriented, not intelligent distress
 Abdominal: Nontender nondistended, bowel sounds confer-upon, incisions cleanlyly dry and intact
 Genitourinary:
 Vagina: Scant unspotted execute in the subsequent fornix
 Cervix: Cervical mucus and Mirena IUD strings noted at the os
 Neurologic: Alert and oriented
 
Assessment/Plan
 

1. Intelligent Chlamydia trachomatis taint of genitourinary locality
 GCC obtained. encouraged condoms acceptably. no signs of PID.
 
****pt contacted and sensible of substantial Chlamydia results. pt sensible that medication has been sent her pharmacy. pt sensible that she was abandoned 500mg dosage so this space she gain charm two pills PO at the corresponding space. pt sensible that her companion can go to the heartiness portion for tenor. pt sensible that the third cause needs to be manageed as courteous-mannered. pt educated on the signification of all parties substance manageed to abated pitfall and reinfection. pt verbalized intelligence, no raise questions at this space.

99214 employment outunrepining investigate 25 minutes (Charge), Quantity: 1, Intelligent Chlamydia trachomatis taint of genitourinary locality | Vaginal execute
 
2. Vaginal execute
 Affirm attentive. manage per results.