SOAP
NOTE
Name: RC Date: 6/30/2020 Time: 1000 Log # 5051763 Age: 22 Sex: Female
SUBJECTIVE
CC: “I have been having vaginal discharge for the last two weeks”
HPI:
RC is a 22-year-old white female G0P0AB0 who presents to the clinic complaining of a small
amount yellowish vaginal discharge with an odor that began about two weeks ago. Complains of pain
during s intercourse. No change in discharge after using Monistat at home. Patient denies any
cramping, vagin bleeding, indigestion, diarrhea, constipation, and change in stool, hematemesis,
urinary frequency, urg or hematuria.
Patient provided the HPI as follows:
O – Onset of symptoms started two weeks ago L – Vaginal discharge
D – Symptoms have lasted for the last two weeks C – Reports yellowish vaginal discharge
A – Sexual intercourse aggravates her symptoms
R – Reports no abdominal pain or cramping
T – Two weeks T – Monistat
S – Rates symptoms 3/10 with intercourse
Medications:
1Tri Sprintec- one tab daily for birth control
2Tylenol 500 mg 2 tablets q 6 hours as needed for pain.
PMH
Allergies: No known drug, food, latex, or environmental allergies
Medication Intolerances: None Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: Appendectomy in 2011.
Family History
Mother: Age 44. No known medical problems.
Father: Age 46. Hypertension, Hyperlipidemia and Reflux. Paternal GM: Age 65. HTN, chronic pain and obesity.
Paternal GF: Deceased @ 63 due to MI, history of HTN.
Sister: Age 19. No known health problems
Social History
Education Level: High school graduate.
Occupational history: Works full time as cashier. Current living situation: Lives at home with her parents.
Substance use/abuse: Denies substance use/abuse.
ETOH: Denies use.
Tobacco Use: Never smoked
Safety Status: She states she always uses her seat belt while driving. Home environment is safe and fr
from physical hazards and emotional abuse.
ROS
General
Patient denies fatigue, fever, chills. Denies weight change and night sweats. Denies lack
of appetite.Cardiovascular
Denies chest pain, palpitations, PND, orthopnea, and
edema.
Skin
Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes
in lesions or moles.Respiratory
Denies cough, wheezing, hemoptysis, dyspnea, pneum
or TB history.
Eyes Gastrointestinal
Patient denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma,
peripheral visual changes, and dry eyes.Patient denies constipation, hepatitis, hemorrhoids, ulc
black tarry stools.
Ears
Denies ear pain, hearing loss, ringing in ears,
discharge.Genitourinary/Gynecological
Denies any urgency, frequency burning, change in col
urine. Admits to painful intercourse for the last two w
her with boyfriend. Admits to using birth control pill
f contraception
Last Pap: States last Pap smear normal in 2016.
Breast Self-Exam: Admits to conducting breast self-
e monthly.
Mammogram: States she has never had a
mammogra
Menstrual complaints : Denies any menstrual
compla with last LMP two weeks ago.
Vaginal discharge: yellowish vaginal discharge
with odor that began about two weeks ago.
Pregnancy history: Denies any pregnancy history. On sexual activity with males at age 17, admits to 6 partn but the last year only with her boyfriend. Denies
histo STIs. She reports menarche at age 12.
Nose/Mouth/Throat
Patient denies sinus problems, dysphagia,
nose bleeds/discharge, dental disease, hoarseness, and throat painMusculoskeletal
Denies back pain, joint swelling, stiffness or pain, frac
history, osteoporosis.
Breast
Denies lumps, bumps or breast changes.Neurological
Denies syncope, seizures, transient paralysis, weaknes paresthesias, black out spells.
Heme/Lymph/Endo
Denies blood transfusion history. Denies bruising, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance.Psychiatric
Denies any sleeping difficulties or suicidal ideations
OBJECTIVE (Document in the Inspection, Palpation, Percussion, Auscultation) format except o
Abdomen (IAPP)
Weight: 142lbsBMI: 23.9Temp: 98.5 FBP: 122/64 mmHg
Height: 5ft 6 inches Pulse: 76 beats/min Respirations: 16 breaths/min General Appearance : RC is a healthy-appearing well-nourished 22-year-old female in no acute distress. She is alert/oriented
and is dressed appropriate in clean clothing.
Skin
Patient’s skin is pink and appropriate to her ethnicity, warm, dry, clean and intact. No rashes or lesions noted.
HEENT
Head is normocephalic and without lesions; hair evenly distributed. No tenderness at facial and maxill
sinuses. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilate
TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink. No deviation. Neck: Supple with full ROM; cervical lymphadenopathy present and palpable; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is non-erythematous and wi exudate.
Cardiovascular
S1, S2 with regular rate and rhythm, no clicks, rubs or murmurs. Capillary refill is normal with pulses
throughout. No edema noted.
Respiratory
Respirations regular and unlabored with symmetric chest wall. Lung sounds present and clear to auscultation in all fields. No anterior or posterior crackles/wheezes.
Gastrointestinal
Soft non- distended abdomen. Active bowel sounds x 4 quadrants. Tympanic percussion sounds x 4 quadrants. Non-tender abdomen with palpation x 4 quadrants. No hepatosplenomegaly appreciated on
palpation.
Breast
Symmetric, tender, without mass. No swelling, ulceration, or discharge noted.
Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia without erythema, lesions or masses. inguinal adenopathy. No vulvar lesions noted. External genitalia: no lesions noted, vaginal walls pink,
hair, scant, shaven. Vagina: Mucosa moist and slightly reddened. Small amount of yellowish vaginal discharge noted. Cervix: pink, w/o lesion or mass. Bimanual exam: lower pelvic tenderness, no palpa uterine or ovarian enlargement. Rectum is appropriate; no evidence of hemorrhoids, fissures, bleeding
masses.
Musculoskeletal
No joint deformities and good range of motion noted as patient moved about the exam room.
Neurological
CN11-X11 intact. Good coordination with normal gait and balance.
Psychiatric
Alert and oriented. Maintains eye contact. Speech is clear and answers questions appropriately. Denie
suicidal ideation.
Lab Tests
Pap smear and culture- positive for trichomoniasis.
Special Tests
None
Diagnosis
Differential Diagnoses
NOTE
Name: RC Date: 6/30/2020 Time: 1000 Log # 5051763 Age: 22 Sex: Female
SUBJECTIVE
CC: “I have been having vaginal discharge for the last two weeks”
HPI:
RC is a 22-year-old white female G0P0AB0 who presents to the clinic complaining of a small
amount yellowish vaginal discharge with an odor that began about two weeks ago. Complains of pain
during s intercourse. No change in discharge after using Monistat at home. Patient denies any
cramping, vagin bleeding, indigestion, diarrhea, constipation, and change in stool, hematemesis,
urinary frequency, urg or hematuria.
Patient provided the HPI as follows:
O – Onset of symptoms started two weeks ago L – Vaginal discharge
D – Symptoms have lasted for the last two weeks C – Reports yellowish vaginal discharge
A – Sexual intercourse aggravates her symptoms
R – Reports no abdominal pain or cramping
T – Two weeks T – Monistat
S – Rates symptoms 3/10 with intercourse
Medications:
1Tri Sprintec- one tab daily for birth control
2Tylenol 500 mg 2 tablets q 6 hours as needed for pain.
PMH
Allergies: No known drug, food, latex, or environmental allergies
Medication Intolerances: None Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: Appendectomy in 2011.
Family History
Mother: Age 44. No known medical problems.
Father: Age 46. Hypertension, Hyperlipidemia and Reflux. Paternal GM: Age 65. HTN, chronic pain and obesity.
Paternal GF: Deceased @ 63 due to MI, history of HTN.
Sister: Age 19. No known health problems
Social History
Education Level: High school graduate.
Occupational history: Works full time as cashier. Current living situation: Lives at home with her parents.
Substance use/abuse: Denies substance use/abuse.
ETOH: Denies use.
Tobacco Use: Never smoked
Safety Status: She states she always uses her seat belt while driving. Home environment is safe and fr
from physical hazards and emotional abuse.
ROS
General
Patient denies fatigue, fever, chills. Denies weight change and night sweats. Denies lack
of appetite.Cardiovascular
Denies chest pain, palpitations, PND, orthopnea, and
edema.
Skin
Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes
in lesions or moles.Respiratory
Denies cough, wheezing, hemoptysis, dyspnea, pneum
or TB history.
Eyes Gastrointestinal
Patient denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma,
peripheral visual changes, and dry eyes.Patient denies constipation, hepatitis, hemorrhoids, ulc
black tarry stools.
Ears
Denies ear pain, hearing loss, ringing in ears,
discharge.Genitourinary/Gynecological
Denies any urgency, frequency burning, change in col
urine. Admits to painful intercourse for the last two w
her with boyfriend. Admits to using birth control pill
f contraception
Last Pap: States last Pap smear normal in 2016.
Breast Self-Exam: Admits to conducting breast self-
e monthly.
Mammogram: States she has never had a
mammogra
Menstrual complaints : Denies any menstrual
compla with last LMP two weeks ago.
Vaginal discharge: yellowish vaginal discharge
with odor that began about two weeks ago.
Pregnancy history: Denies any pregnancy history. On sexual activity with males at age 17, admits to 6 partn but the last year only with her boyfriend. Denies
histo STIs. She reports menarche at age 12.
Nose/Mouth/Throat
Patient denies sinus problems, dysphagia,
nose bleeds/discharge, dental disease, hoarseness, and throat painMusculoskeletal
Denies back pain, joint swelling, stiffness or pain, frac
history, osteoporosis.
Breast
Denies lumps, bumps or breast changes.Neurological
Denies syncope, seizures, transient paralysis, weaknes paresthesias, black out spells.
Heme/Lymph/Endo
Denies blood transfusion history. Denies bruising, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance.Psychiatric
Denies any sleeping difficulties or suicidal ideations
OBJECTIVE (Document in the Inspection, Palpation, Percussion, Auscultation) format except o
Abdomen (IAPP)
Weight: 142lbsBMI: 23.9Temp: 98.5 FBP: 122/64 mmHg
Height: 5ft 6 inches Pulse: 76 beats/min Respirations: 16 breaths/min General Appearance : RC is a healthy-appearing well-nourished 22-year-old female in no acute distress. She is alert/oriented
and is dressed appropriate in clean clothing.
Skin
Patient’s skin is pink and appropriate to her ethnicity, warm, dry, clean and intact. No rashes or lesions noted.
HEENT
Head is normocephalic and without lesions; hair evenly distributed. No tenderness at facial and maxill
sinuses. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilate
TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink. No deviation. Neck: Supple with full ROM; cervical lymphadenopathy present and palpable; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is non-erythematous and wi exudate.
Cardiovascular
S1, S2 with regular rate and rhythm, no clicks, rubs or murmurs. Capillary refill is normal with pulses
throughout. No edema noted.
Respiratory
Respirations regular and unlabored with symmetric chest wall. Lung sounds present and clear to auscultation in all fields. No anterior or posterior crackles/wheezes.
Gastrointestinal
Soft non- distended abdomen. Active bowel sounds x 4 quadrants. Tympanic percussion sounds x 4 quadrants. Non-tender abdomen with palpation x 4 quadrants. No hepatosplenomegaly appreciated on
palpation.
Breast
Symmetric, tender, without mass. No swelling, ulceration, or discharge noted.
Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia without erythema, lesions or masses. inguinal adenopathy. No vulvar lesions noted. External genitalia: no lesions noted, vaginal walls pink,
hair, scant, shaven. Vagina: Mucosa moist and slightly reddened. Small amount of yellowish vaginal discharge noted. Cervix: pink, w/o lesion or mass. Bimanual exam: lower pelvic tenderness, no palpa uterine or ovarian enlargement. Rectum is appropriate; no evidence of hemorrhoids, fissures, bleeding
masses.
Musculoskeletal
No joint deformities and good range of motion noted as patient moved about the exam room.
Neurological
CN11-X11 intact. Good coordination with normal gait and balance.
Psychiatric
Alert and oriented. Maintains eye contact. Speech is clear and answers questions appropriately. Denie
suicidal ideation.
Lab Tests
Pap smear and culture- positive for trichomoniasis.
Special Tests
None
Diagnosis
Differential Diagnoses
