Assignment task: How to write a SOAP note?
Genitourinary Clinical Case
Patient Setting:
28-year-old female presents to the clinic with a 2 day history of frequency, burning and pain upon urination; increased lower abdominal pain and vaginal discharge over the past week.
HPI:
Complains of urinary symptomssimilarto those of previous urinary tractinfections(UTIs) which started approximately 2 days ago; also experiencing severe lower abdominal pain and noted brown fouls smelling discharge after having unprotected intercourse with her former boyfriend.
PMH:
Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III
Past Surgical History:
Tubal ligation 2 years ago.
Family/Social History:
Family: Single; history of multiplemale sexual partners; currently lives with new boyfriend and 3 children.
Social: Denies smoking, alcohol and drug use.
Medication History:
None
Allergy: Trimethoprim (TOM)/ Sulfamethoxazole (SMX) -Rash
ROS
Last pap 6 months ago, Denies breast discharge. Positive for Urine looking dark.
Physical exam:
BP 100/80,
HR 80,
RR 16,
T 99.7 F,
Wt 120,
Ht 5' 0"
Gen: Female in moderate distress.
HEENT: WNL.
Cardio: Regularrate and rhythm normal S1 and S2.
Chest: WNL.
Abd: soft, tender, increased suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.
Rectal: WNL.
EXT: WNL.
NEURO: WNL.
Laboratory and Diagnostic Testing:
Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%
UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria - many, Lkcs 10-
15, RBC 0-1
Urine gram stain - Gram negative rods
Vaginal discharge culture: Gramnegative diplococci, Neisseria gonorrhoeae, sensitivities pending
Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative. Want Online Help?