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Women’s Health Mini SOAP Notes
ICD 10: N39.
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 STD P: 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 area from 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. ICD 10: Z01.419; Z30. 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 gross lesions or lacerations. Vagina shows healthy, pink mucosa, no gross lesions, white discharge noted. 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 discussed her 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
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 one sexual 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 use of 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 for next year. ICD 10: N94.6; Z30. 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 would not 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: 19.4; External: Tanner 5 pubic hair, normal genital development, no lesion. Internal: cervix- nulliparious, os closed, pink with no lesions. Scant clear mucoid discharge. Bimanual: anteverted uterus, normal size with no masses; adnexa- normal, non-tender. A: 16-year-old female Caucasian female, sexually active, with marked dysmenorrhea, in need of contraception. Parent not aware of sexual activity and patient prefers to keep it confidential today. Introduced oral contraceptive pills to patient and mother as a treatment for severe dysmenorrhea. Both mother and patient agreed to a 2-6 month trial of oral contraception along with high dose Ibuprofen. Differential Diagnosis: Endometriosis & PID P: Labs: Denied STD or pregnancy testing right now due to mother being present. Medication: Ortho-Cyclen 28 day. Dis: 1 pack. Sig: 1 tab po qd. Refill: 2 and Ibuprofen 600 mg Dis: 30. Sig: 1 TAB PO TID for dysmenorrhea. Refill: 3. Education: Educated on contraception usage. Informed contest signed. Encouraged condom use when patient’s mother was not present in room. Follow-up: 3 months
A: 26-year-old Caucasian female patient came in with the concern of post coital bleeding, pelvic and bladder pain with occasional dysuria for the last three days. DX: PID. Differential Diagnosis: Mucopurulent Cervicitis & Acute cystitis P: Labs: CBC, urinalysis, cervical culture & wet prep, pending. Pregnancy test: negative Medication: Ceftriaxone 250 mg intramuscularly (IM) once as a single dose plus, Doxycycline 100 mg orally twice daily for 14 days Education: Take medication as prescribed and possible side effects. Avoid chemical irritants such as douches and deodorant tampons. A monogamous sexual relationship with someone who is known to be free of any STD can reduce the risk. Monogamous means you and your partner do not have sex with any other people. Consistent use of condoms greatly reduces the risk of transmission of STDs. Condoms are available for both men and women. A condom must be used properly every time. Increase fluids and urinate more. Recommended cranberry juice to acidify the urine. Encourage proper nutrition and regular physical activity. Follow-up: Return to the clinic immediately if worsening of symptoms such as persistent fever, chills, abnormal discharge or other signs of infection. Otherwise, follow up in two weeks. Call for any questions. ICD 10: N S: “I found a small non-painful lump in my right breast.” Found right-sided lump in breast while during monthly first exam two days ago. No pain but concerned about it being breast cancer, since her aunty (Mom’s sister) was diagnosed with breast cancer 5 years ago. Has never had a mammogram performed. O: Vitals: BP: 122/63, HR: 62 RR: 16 Temp: 98.2 W: 178, H: 5’7, BMI: 27.9. Breast exam: Upper area of right breast palpable, small painless solid mass detected. No dimpling or pitting of skin. No nipple discharge. A: 34-year-old African American female presented with non-painful right breast lump with a family history of breast cancer. DX: Unspecified breast lump Differential Diagnosis: Fibroadenoma or Fibrocystic condition, breast cancer P: Test: Mammogram/ Breast Ultrasound/Biopsy ordered- pending results Medication: None Education: The importance of performing monthly self-breast exams. Keep a journal of any changes of breast and any associated abnormal distinctions. Follow-up: Will call with mammogram results as soon as available.
ICD 10: A60.
S: c/c “I have multiple painful and itchy white pimple-like blisters on the outer part of my vagina.” Two-day history of painful and itchy blisters on outer area of vagina. Burns when urinating and nothing has helped to alleviate it. Last sexual encounter was 2 weeks ago. Uses condoms but not all the time. Admits to having 10 plus lifetime partners. LMP: 12/23/17. Last PAP, unknown. O: Vitals: BP 128/61, HR: 72, RR: 21, Temp: 99.5, H: 5’3, W: 121, BMI: 21.4. External vaginal exam revealed multiple 1-2 millimeter small white pus like lesions grouped in crops on vulva and labia. A: 27-year-old female present with multiple painful and itchy white pimple like blisters on her vagina. Symptoms began 2 days ago and stated that it burns when she urinates. DX: Genital Herpes Differential Diagnosis: HPV, Vulvovaginitis, Syphilis P: Labs: Viral culture, Polymerase chain reaction (PCR) test, CBC-pending Medication: Valtrex 1 g PO q12hr for 10 days Education: No cure for genital herpes. Take all medication as prescribed. No sexual relations until medication is complete. Must use condoms at all times. Wash your hands with soap and water before and after touching blisters. Keep the genital areas clean and dry. If it is painful to urinate, soak in a tub of warm water to relieve pain or try warm cloth compresses to reduce irritation. May use ice packs for pain relief. Use mild soaps. Wear loose fitting clothing. Do not wear panty hose or tight fitting jeans. Wear cotton underwear. Avoid touching the eyes after touching blisters. Herpes can spread to the eyes and cause serious infection, and in rare cases, blindness. Avoid reoccurring blisters. Stress, lack of sleep, and other infections can increase blisters. Healthy lifestyle behaviors can reduce the number and severity of blisters. Limit sexual partners. Practice safe sex. Follow-up: Seek medical attention of symptoms worsen. Come back in 2 weeks for follow up. Will call with lab results. ICD 10: N95. S: “I have been having hot flashes for the past few months, and I just can’t take it anymore.” Reports experiencing 2-3 hot flashes per day sometimes associated with insomnia. She also states she is awakened from her sleep, soaked by night sweats, about 1-2 times per week needing to change her pajamas and bedding. Her symptoms began about 6 months ago, and over that time, they have worsened to the point where they have become very annoying. LMP: About 4 years ago; some spotting but nothing major. Last PAP: year ago. She states that her mother was prescribed hormones for this, but she is cautious to take them because she has heard that the medication may not be safe.
shark, swordfish, tilefish, and king mackerel. Work/low-impact activities; encourage walking daily. Standard education packet provided to patient. Patient referred to OBGYN. Follow-up: Will call with test results. Seek medical treatment immediately if bleeding, fever, ROM, contractions, severe or sudden swelling. If positive STD, then RTO in 4 weeks for recheck. ICD 10: N76. S: “I have foul smelling vaginal discharge and itching at times for 2 weeks.” Patient reported being sexually active with one partner for the last year and that the itching gets bad after intercourse. History of yeast infection 3 months ago had a dose of Diflucan left, which she used when the symptoms started, however it did not help her. No history of STD. Denies any other symptoms at this time. O: Vitals: BP: 102/60, HR: 65, RR: 16, Temp: 98.6 W: 116, H: 5’4, BMI: 19.9. Bladder is non- distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. Foul smelling discharge present on examination, reports occasional itching. No hemorrhoids or fissures noted. A: 21-year-old female present with a two-week history of foul smelling vaginal discharge. DX: Bacterial Vaginitis Differential Diagnosis: UTI, Candidiasis, Gonorrhea, Other Sexually Transmitted Infections P: Labs: Urinalysis – Negative urine dipstick, pregnancy test negative; CBC, CMP, TSH – pending; Cervical swab culture – pending; Pap smear, STD testing – pending Medication: Metronidazole 750mg once daily for 7 days. Take 1 hr. before or two hrs. after meals Education: Complete entire course of antibiotics for treatment, even if the symptoms resolve after a few doses. Educated no to douche, perfumed soaps and feminine hygiene sprays to avoid irritation to vagina. Importance of maintaining hygiene and washing genital area after sexual intercourse. The patient agrees with the current treatment plan and verbalizes their complete understanding. Follow-up: RTO in 3 days for test results or sooner if symptoms worsen.
ICD 10: D25.
S: c/c Pelvic pain. LMP was about 8 months ago. She is not sexually active. She complains of symptoms of increasing pressure and pain in her pelvic area. She reports a small increase in urinary frequency and but no change in bowel habits. In addition, she complains of hot flashes and night sweats. She was recently treated with oral contraceptives, which resulted in a decrease in her hot flashes and night sweats. She also complains of shortness of breath upon walking up and down stairs and there is occasional swelling of her feet. O: Vitals: Temp: 98.6 HR: 72 RR: 18 BP: 120/70 W: 162 H: 5’5 BMI: 27.0. Abdomen: Palpable mass at the level of her umbilicus. She is tender to palpation in the left lower quadrant. Pelvic: External genitalia are normal. The urethral meatus, urethra and bladder are normal. The vaginal vault and cervix are visualized and appear normal. The uterus is palpable above the umbilicus and estimated to be approximately 20 centimeters in greatest diameter. The mass is irregularly-irregular and firm, consistent with leiomyoma’s (benign tumor of the uterine smooth muscle). The adnexa (appendages of an organ – in this case, the uterine tubes, ligaments and ovaries) cannot be palpated because of the enlarged uterus. A: 45-year-old Caucasian female presented with pelvic pain, small increase in urinary frequency. Complaints of hot flashes and night sweats. DX: Uterine fibroids (leiomyoma’s) Differential diagnosis: Leiomyosarcoma, Mastocytosis, Dermatofibroma P: Labs: CBC, Urinalysis, FSH- pending Special testing: Pelvic ultrasound pending Medication: None at this time Education: Discussed using as form of birth control and or IUD but patients does not want to. She has opted to just take OTC ibuprofen for pain, until after her pelvic ultrasound and lab results are in. Provided patient with other treatments such as surgery, depending on her test results. Patient is aware that surgery may be needed and is okay with it. Follow-up: RTO in one week for test results or sooners if symptoms persist.
rugae present. Small amount of thin, clear non-odorous discharge noted. No evidence of prolapse. Cervix: pink, non-friable without lesion or mass. Adnexa: Mobile, mild right ovarian tenderness, no palpable uterine or ovarian enlargement. Anus: No hemorrhoids or fissure noted. Lymph: No inguinal lymphadenopathy. A: 17- year- old Caucasian female with DX of Amenorrhea, secondary. Differential Diagnosis: Thyroid dysfunction, PCOS, Ovarian tumor P: Labs: HgbA1C, LH, FSH, estradiol, Prolactin, total testosterone, free testosterone, DHEAS, TSH, Lipid panel; Results pending Wet mount smear with saline and KOH; Results: Negative for yeast, clue cells, and trichomonads Urine Pregnancy Test: negative Infectious agent detection by nucleic acid (cervical swab): Neisseria gonorrhea; Results Pending Infectious agent detection by nucleic acid (cervical swab): Chlamydia trachomatis; Results Pending. Special testing: Transvaginal ultrasound for RLQ tenderness to r/o ovarian cyst: Results Pending. Medication: Provera 10 mg, 1 tab PO QHS x 10 days; Disp. 10, no refills; Desogen (desogestrel 0.15mg/ethinyl estradiol 30mcg) one tab PO daily; begin pack on first day of menstrual cycle. Disp # 1, 11 refills Continue multivitamin, 1 PO daily Continue OTC Ibuprofen 400mg PO Q 4-6 hrs. prn for cramps. Education: Provera: Begin taking Provera this evening and take one daily for a total of 10 days; Once finish Provera can expect withdrawal bleeding to begin any 5-14 days. If you do not begin your cycle after 20 days, contact our office. Desogen: Begin oral contraceptive pill (ocp) on day of one of menstrual bleeding, then take daily as directed at the same time each day. Use a back- up form of protection such as condoms to prevent pregnancy during the first week after beginning OCPS. Note that several medications including antibiotics may alter the effectiveness of your OCPS. Always check for interaction with your provider prior to beginning any new medications. While OCPS are very effective at pregnancy, prevention they do not protect you from STDs, so gain use condoms in tandem with OCPS. Patient reminded of the importance of not smoking or using tobacco. Risk reviewed along with other contraception options, and I feel the patient understands. Pt. encouraged continuing daily exercise and eating a well-balanced diet. Follow-up: Will review lab results and ultrasound results at follow up appointment in two weeks; will notify patient via phone of any critical labs or findings when received. ICD 10: A
S: c/c “I’ve been having itching, foul odor and some white secretions on my private areas.” Patient complaints of bad odor with white-yellowish secretions in her private area that has gotten worse in the last 3 days. No contraception use reported, sexually active, with husband of 3 years last Pap smear 3 months ago; normal. Negative for STDS. No pregnancy, miscarriage or abortion reported. LMP: about 3 weeks ago. First menses: at age 16 O: Vitals: W: 127, H: 5’4, BMI: 21.8, Temp: 98.1, BP: 108/74, HR: 64, RR: 16. Bladder is non- distended, pubic hair is adequate for age and gender and skin color with consistent with general pigmentation. Slight swelling noted in external genitalia foul odor and white-yellowish discharge consistent with patients complains. No vulvar lesions noted. During examination with speculum, cervix was pink and mobile. No inguinal lymphadenopathy noted. A: 26-year-old African American female with DX of Trichomoniasis Differential Diagnosis: Bacterial Vaginosis, Chlamydia, Candidiasis, Gonorrhea, P: Labs: Culture sent to lab to test for HIV, Syphilis, Chlamydia, and gonorrhea. Pregnancy test: negative Medication: Metronidazole (Flagyl) 2 grams orally single dose. Education: Patient and partner educated to avoid sexual interactions until treatment is finished and symptoms are no longer present. Instructions given to avoid alcohol consumption during treatment and for 24 hours after finishing. Follow-up: Will review lab results and call patient with results. If symptoms get worse RTO. ICD 10: Z S: Patient brought in by her Mother stating, “My daughter needs her HPV vaccination.” No medical history. Has not begun menstrual cycle. All up-to-date on vaccination (-) HPV O: Vitals: HR: 88, RR: 20, B/P: 107/ 82, W: 87 H: 4’5, BMI: 21.8 (81 percentile). A: 13-year-old female presented with her mother for HPV vaccination No Differential Diagnosis P: Labs: None Medication: 9-valent/9vHPV (Gardasil 9), 500-μg amorphous aluminum hydroxyphosphate sulfate, IM, single dose Education: Most common side effect reported is pain, swelling, and redness in the arm where the shot was given. This vaccination helps to protect patient from STDs. Provided patient and mother with patient education handout on HPV and STDs. Follow-up: None needed
has an endometrial ablation two years ago and her sex drive has not been the same. She states that she has intercourse about once a month with her husband of 12 years because she feels like she has to, not because she wants to. Denies any pain during sex, discharge, frequency in urination. O: Vitals: BP 121/74, HR: 72, RR: 16, W: 156, H: 5’7, BMI: 24.4 Temp: 98.2. Breast: Examined in upright and recumbent positions. Smooth and symmetric in contour. No axillary or supraclavicular lymphadenopathy. Mild diffuse nodularity throughout both breasts. No dominant or suspicious masses, nipple discharge or retraction. Genitourinary: No bladder distention; no CVA tenderness noted/reported. No inguinal lymph node enlargement. Normal appearing external female genitalia. No lesions or redness. Speculum: Vaginal walls moist, pink and rugose. Scant clear discharge in vault. Cervical cuff visualized with ease. No gross lesions. Bimanual: Uterus mobile, non-tender, not enlarged. No adnexal masses or tenderness. Rectal: Negative Heme A: 49-year-old female presented for annual PAP and lack of sexual drive. DX: Sexual dysfunction in women/Hypoactive sexual desire disorder (No sex drive) Differential Diagnosis: Material Discord, Secondary Sexual aversion, Hormonal imbalance P: Labs: Wet Prep, TSH, Prolactin Levels, Hormone Levels, Urinalysis, CBC (pending). Special test: Ordered mammogram Medication: Chantix 0.5 mg once daily for 3 days; 0.5 mg twice daily; then 1 mg twice daily for 8-10 but no longer than 12 day to help quit smoking. Education: Take medication as prescribed. If you experience any massive mood swing or have, suicidal thoughts discontinue and call office for appt. alternatively, head to the ER if side effects are more severe. Patient advised to enhance your sexual wellbeing by improving correspondence with your accomplice and settling on sound way of life decisions. Talking and tuning in to each other, look for guiding, and Practice sound way of life propensities. "Stay away from unnecessary liquor. Drinking excessively will limit your sexual responsiveness. Likewise, quit smoking and begin working out. Cigarette smoking limits blood stream all through your body, and less blood achieving your sexual organs implies diminished sexual excitement and orgasmic reaction. Customary vigorous exercise can build your stamina, enhance your self-perception and hoist your inclination, helping you feel more sentimental, even more regularly. Follow-up: One month or sooner, if symptoms increase or side effects are troublesome from Chantix. Referral to psychologist for talk therapy. ICD 10: Z01. S: “I am here for my annual checkup.” G2P2 here for annual exam. Regular menses q 28 days with no intermenstrual bleeding. IUD for contraception since birth of last child 2 years ago. No
problems with method. Minimal dysmenorrhea. Mutually monogamous relationship x 6 years. No hx of abnormal Paps. + BSE, jogs twice a week, no smoking, no abuse O: Vitals: BP: 112/86, HR: 68, RR: 21, Temp: 98.3, W: 102, H: 5’3, BMI: 18.1. Breasts: No masses, adenopathy, skin changes Abd: No masses, soft, NT Pelvic: Ext genitalia: Normal Vagina: pink, moist, well rugated Cervix: multiparous, no lesions Bimanual: uterus small, anteverted, NT, no adnexal masses or tenderness A: 23-year-old female here for annual GYN exam. Normal exam. No differential diagnosis. P: Labs: Lipid panel, Chlamydia and gonorrhea testing, CBC, TSH, Cervical cytology, pending. Negative for pregnancy Medication: Patient does not want to be placed on birth control at this time. Education: Discussed safe sex practices and the use of condoms. Healthy diet and regular exercise was also addressed. Also discussed possible birth control methods. Patient will think it over, but does not want to be on any right now. Follow-up: Pap, RTC 1 year ICD 10: R10. S: “I am here for a follow up of chronic left sided pelvic pain.” G3P1 with LMP 1 week ago. Patient first seen 5 months ago with complaints of pain x 2 years. She describes pain as dull and aching, intermittent, with no relationship to eating but increased before and during menses. Pain has gotten worse over the last 5 months and requires her to miss work 2-3 days per month. No relief with NSAIDs. Patient has history of chlamydia 5 years ago for which she was treated. No history of PID. Three partners within the past year: no condom use. No GI symptoms: regular BMs, no constipation, diarrhea, nausea or vomiting. History of ectopic x 2 with removal of part of the left and right tubes. Also had ruptured appendectomy at age 20. On birth control pills for contraception. O: Vitals: BP: 128/ 89, HR: 92, RR: 22, Temp: 99.3; W: 194, H: 5’6, BMI: 32.0. Abdomen: 1+ LLQ tenderness, no peritoneal signs Pelvic: Ext genitalia: Normal. Vagina: no discharge. Cervix: no lesions. Biman: uterus small, retroverted, NT, 3+ left adnexal tenderness, no right adnexal tenderness, and no masses palpated. A: 34-year-old African American female here for follow up for chronic left sided pelvic pain. Pelvic pain unresponsive to medical management treatment. Differential Diagnosis: Endometriosis, Adhesive disease, PID P: Labs: CBC count and sedimentation rate, Serum drug screen, Urinalysis and urine culture, STD tests, Follicle-stimulating hormone level, estradiol level, and gonadotropin-releasing hormone agonist stimulation, TSH: all pending Special testing: Schedule diagnostic laparoscopy
use condom with each act of intercourse, limit the number of sexual partners, screening for new sexual partners, and do not have sexual activity until all your symptoms are gone and your partner has completed antibiotic therapy. Follow-up: Referred to gynecologist for IUD evaluation and possible removal. Reevaluation in 4 to 6 weeks after completion of therapy. If positive cultures for gonorrhea and chlamydia, the patient should be recultured in 7 to 10 days after completing therapy.
