Soap 1

Select a accommodating that you advised during the aftermost three weeks. With this accommodating in mind, abode the afterward in a SOAP Note:

  • Subjective: What capacity did the accommodating accommodate apropos her claimed and medical history?
  • Objective: What observations did you accomplish during the concrete assessment?
  • Assessment: What were your cogwheel diagnoses? Accommodate a minimum of three accessible diagnoses. List them from accomplished antecedence to everyman priority. What was your primary analysis and why?
  • Plan: What was your plan for affection and primary diagnosis? What was your plan for analysis and management, including another therapies? Include pharmacologic and nonpharmacologic treatments, another therapies, and aftereffect parameters, as able-bodied as a account for this analysis and administration plan.
  • Reflection notes: What would you do abnormally in a agnate accommodating evaluation?

Patient Information:

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
 Genitourinary: Negative
 Gynecological: see HPI
 Neurologic: Negative
 Psychiatric: Denies all-overs 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 astute distress
 Abdominal: Nontender nondistended, bowel sounds present, incisions apple-pie dry and intact
 Genitourinary:
 Vagina: Scant white acquittal in the after fornix
 Cervix: Cervical fungus and Mirena IUD strings acclaimed at the os
 Neurologic: Alert and oriented
 Assessment/Plan 
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.

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