SOAP Note Example XX, 27yowf, NKDA CC: I have very bad smelling discharge from my vagina.

S: HPI: 27 yowf. Setting: health department, hx per pt. Hx: 3w bad smelling discharge from my vagina, thick, white, and seems heavier in the morning, no aggravating or reliving factors noted. Social hx: Lives c boyfriend + 1 child in single home, not working, denies any exposure to smoke at home and denies smoking. Reports 1 regular sex partner and 7 lifetime partners. States does not always use condoms, but knows the importance of using one. Med hx: + for 1 (2006) c-section delivery of twins, dx of Chlamydia in March 2012, May 2006, and June 2008, and dx of Gonorrhea in May 2007. Fam hx: + for HTN and Thyroid CA. Diet/Exercise: jogging 3x/wk, states I try to eat healthy stuff when I have time. Pregnancy hx: G2T1P1A0L1 Twins at 21 weeks via C-section due to complications with pregnancy Menstrual hx: LMP two weeks ago c heavy but normal flow x5-7d, no bleeding/spotting since then, last PAP unknown, no previous mammo ROS: Denies HA, neck/back pain, abd pain, muscle weakness/pain, malaise, pelvic cramping, dysuria, s in bowel or bladder habits, breast tenderness, nipple darkening, unusual vaginal itching or burning, or n/v Current Meds: BC Patch: Ortho Evra (0.02mg/0.15mg)/24 hours apply to skin each week x 3 weeks, then off one week (days 22-28), and repeat cycle O: Height not taken, 108lbs, 128/64, temp not taken, pulse not taken, 20 Exam: Well-nourished, A&Ox3, skin PWD, head normocephalic, eyes and ears not examined due to time constraints, thyroid not enlarged, lungs CTA, CVRRR, cervical/axillary lymph nodes non-palpable, bilat breasts non-tender to palp, areolas light pink, no palpable nodes, abd S/NT, BS not auscultated due to time constraints, adequate muscle tone + full AROM x4, no edema noted, cap refill <2sec, PELVIC: ext genitalia + vaginal walls pink, pubic hair scant and shaven, cervix intact, closed os, thick white foul smelling discharge noted in vaginal canal, lower pelvic tenderness on bimanual exam, uterus smooth and within normal limits, ovaries not palpable LABS: Gonorrhea, Trichomoniasis, and Chlamydia culture results pending A: Dx: Bacterial Vaginosis Diff. Dx: Trichomoniasis, Gonorrhea, Chlamydia P: Medication: Flagyl 500 mg bid for 1 week for Bacterial Vaginosis

Teaching: Proper wiping, no tub baths, use of condoms, no douching, teach why partner should clean around his foreskin b/f sex. Patient states she understands instructions and has no questions. F/U: As Needed