Select a accommodating that you advised during the aftermost three weeks. With this accommodating in mind, abode the afterward in a SOAP Note:
Chief Complaintvaginal acquittal and odor History of Present Illness21 yo presents with c/o vaginal discharge. she did accept absolute chlamydia on 1/5/17 and states that she and her accomplice were treated. She denies accepting action back that time.. she has not had a TOC. describes acquittal as actuality ablaze and actuality present for 1 week. There is an odor but it is not a ambiguous odor.. She additionally wants to apperceive if she is able to use represh articles to anticipate vaginal discharge. She denies any belly pain, fever Review of SystemsConstitutional: Denies fevers chills
Gastrointestinal: Denies abhorrence airsickness diarrhea, belly pain
Gynecological: see HPI
Psychiatric: Denies all-overs and depression
Vitals & Measurements
HR: 77 (Peripheral) BP: 116/71
HT: 64.5 in WT: 175.8 lb BMI: 29.71 Gen.: Alert and oriented, not astute distress
Abdominal: Nontender nondistended, bowel sounds present, incisions apple-pie dry and intact
Vagina: Scant white acquittal in the after fornix
Cervix: Cervical fungus and Mirena IUD strings acclaimed at the os
Neurologic: Alert and oriented
1. Astute Chlamydia trachomatis infection of genitourinary site
GCC obtained. encouraged condoms consistently. no signs of PID. ****pt contacted and abreast of absolute Chlamydia results. pt abreast that medication has been beatific her pharmacy. pt abreast that she was accustomed 500mg dosage so this time she will booty two pills PO at the aforementioned time. pt abreast that her accomplice can go to the bloom administration for treatment. pt abreast that the third affair needs to be advised as well. pt accomplished on the accent of all parties actuality advised to bargain acknowledgment and reinfection. pt verbalized understanding, no added questions at this time.
99214 appointment outpatient appointment 25 account (Charge), Quantity: 1, Astute Chlamydia trachomatis infection of genitourinary armpit | Vaginal discharge 2. Vaginal discharge
Affirm collected. amusement per results.