STUDYGUIDESOOLUTIONS
WOMEN’S HEALTH MINI SOAP NOTES LATEST
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A.Qualified,vsu
ICD 10: N39.0
S: Burning and pain with urination for 3 three days. Stated that her
urine looks cloudy and has a foul odor. Denies fever, nausea,
vomiting, myalgia, flank pain, blood in urine, any vaginal discharge,
and, vaginal/vulvar irritation. She is sexually active, has same
partner for last 4 years.G1P1001, with normal vaginal delivery.
Menarche age 11. Last menses one week ago; regular 4-5 days.
Tested for STD one year ago. Negative for Chlamydia and
Gonorrhea.
O: Vitals: BP: 125/85 Pulse: 70 RR: 16 Temp: 98.1 W: 156 H: 5’6 BMI:
25.2. Pelvic exam was normal.
A: 24-year-old female presented with 3-day complaints of burning and
pain with urination. Cloudy urine with foul smell.
Differential Diagnosis: Bacterial
vaginosis or STDP: Labs: Urine
culture: pending Medication: Cipro
250 mg PO q12hr for 3 days
Education: Adhere to medication regimen. Instructed on personal
hygiene; wash the perineal areafrom front to back and wear only
cotton underwear. Avoid sexual intercourse until medication regimen
has been completed and you no longer have symptoms. Increase
fluid intake.
Follow-up: If symptoms worsen, come back to office. Will call with
test results in 48 hours.
1
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A.Qualified,vsu
ICD 10: Z01.419; Z30.09
S: Yearly OB exam and refill BC. LMP was 3 weeks ago. Last pap &
STD test one year ago. Menarche age 13. Sexual active with one
lifetime partner. Uses condoms 50% of the time. G0P0.
O: Vitals: Temp: 98.8: BP- 110/67: HR: 68: H: 5’7; W 178; BMI: 27.9.
Pelvic exam: No
bladder tenderness upon palpation, no distention noted. External
genitalia normal, no
2
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A.Qualified,vsu
gross lesions or lacerations. Vagina shows healthy, pink mucosa, no
gross lesions, white dischargenoted. Cervix shows no lesions. Wet
prep has normal results.
A: 19-year-old female presented for yearly OB exam, which after
reviewing the patient’s records,it is noted that this is appropriate.
Patient is sexually active and on oral contraceptives, therefore pap
was recommended. Patient has requested a refill on her oral
contraceptives and has discussedher usage of back up birth
control when she occasionally misses a dose of medication.
No differential diagnosis
P: Labs: Pap smear: Pending; Wet Prep:
Normal Medication: Tri Sprintec, 1 pill PO
daily, disp #1, 11 refills
3
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WOMEN’S HEALTH MINI SOAP NOTES LATEST
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A.Qualified,vsu
Education: Encouraged patient to continue to use a backup form of
birth control is OCs are missed. Reiterate the importance of taking
this medication as directed and maintaining only onesexual
partner. Oral contraceptives can cause DVTs. Do not smoke while
taking OCs, as it increases the risk of DVT. Certain medications
decrease the effectiveness of OCs. If you are placed on a new
medication, ensure that interactions are checked. If you miss a
dose, take that dose as soon as possible. If two doses are missed,
take two pills immediately, then continue taking one pill daily. If
this occurs, use a form of back up birth control for up to 7 days.
The useof OCs do not prevent against the transmission of HIV,
AIDS or other STDs. Begin self -breast exams on a monthly basis.
Follow-up: Will call patient with test results if abnormal. Otherwise,
schedule annual Pap fornext year.
ICD 10: N94.6; Z30.09
S: Follow up for severe menstrual cramps. LMP 12/15/17; occurs every
28-30 days. Days of flow: 3-5. Has missed one day of school every
time she has a period. First menses age 13.
Takes OCT Ibuprofen with no relief. Uses heat pad, helps a little
with abdominal discomfort. Denies other symptoms such as vaginal
discharge, dysuria, fever, or abdominal pain at times other than
menstruation. Admits that she is sexual active with two life
partners. Last sexual encounter was about a month or so ago. Uses
condoms but not all the time. Has not had a pelvic exam not has
been tested for STD, since her mother does not know that she has
been sexually active and wouldnot like her mother to find out.
Interested in birth control.
O: Vitals: Temp: 98.7, HR: 88, RR: 18, BP: 110/68; H: 5' 4, W: 113, BMI:
4
19.4; External: Tanner
