soap 1

Select a patient that you examined during the last three weeks. With this patient in mind, address the following in a SOAP Note:Subjective: What details did the patient provide regarding her personal and medical history?Objective: What observations did you make during the physical assessment?Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.Reflection notes: What would you do differently in a similar patient evaluation?Patient Information:Chief Complaintvaginal discharge and odorHistory of Present Illness21 yo presents with c/o vaginal discharge. she did have positive chlamydia  on 1/5/17 and states that she and her partner were treated. She denies having intercourse since that time.. she has not had a TOC. describes discharge as being light and being present for 1 week. There is an odor but it is not a fishy odor.. She also wants to know if she is able to use represh products to prevent vaginal discharge. She denies any abdominal pain, feverReview of SystemsConstitutional: Denies fevers chillsGastrointestinal: Denies nausea vomiting diarrhea, abdominal painGenitourinary: NegativeGynecological: see HPINeurologic: NegativePsychiatric: Denies anxiety and depressionPhysical ExamVitals & MeasurementsHR: 77 (Peripheral)  BP: 116/71HT: 64.5 in  WT: 175.8 lb  BMI: 29.71Gen.: Alert and oriented, not acute distressAbdominal: Nontender nondistended, bowel sounds present, incisions clean dry and intactGenitourinary:Vagina: Scant white discharge in the posterior fornixCervix: Cervical mucus and Mirena IUD strings noted at the osNeurologic: Alert and orientedAssessment/Plan1. Acute Chlamydia trachomatis infection of genitourinary siteGCC obtained. encouraged condoms consistently. no signs of PID.****pt contacted and informed of positive Chlamydia results. pt informed that medication has been sent her pharmacy. pt informed that she was given 500mg dosage so this time she will take two pills PO at the same time. pt informed that her partner can go to the health department for treatment. pt informed that the third party needs to be treated as well. pt educated on the importance of all parties being treated to reduced exposure and reinfection. pt verbalized understanding, no further questions at this time.99214 office outpatient visit 25 minutes (Charge), Quantity: 1, Acute Chlamydia trachomatis infection of genitourinary site | Vaginal discharge2. Vaginal dischargeAffirm collected. treat per results.

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