Soapnote1.docx – Assignment:




Please use the following information to complete a soap note. Follow the prompts in the template. If you don’t see the information, be creative and make it.

44 y/o Hispanic female. G2T2P0A0L2
Presented at the office for annual Gynecological exam.
Reports pelvic pain and yellow discharge with a foul odor starting 1 week ago.
PMH of fibroid constated in the US. No chronic diseases.
Family history of Mother Type II DM, Father HTN. Sister with HTN and Brother HDL history.
Social history: No tobacco, no alcohol, no illicit drugs. Established 1 sexual partner for the last 10 years. No using a condom
PE. Yellow and foul discharged, tenderness on bimanual exam.
Breast exam and cervix exam performed.
Pap collected
STI screening ordered NuSwab (VV and candida Gsp) collected.
Safe sex practices encourage.
Mammogram ordered.
The US was ordered.
Metronidazole 500 mg 1 tab BID PO for 7 days.
RTO in 3 weeks for results.

Please fallow actual guidelines for diagnosis and treatment
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