Soap Note Template

Name: 

Date: 

Time:

Age:

Sex:

SUBJECTIVE

CC: “I am here for my annual exam and I also have these chancre-like wounds on my vagina for about a week. ”

HPI:

JC is a 20- year-old female G0P0AB0 who presents to the clinic today for annual well woman exam.  She states she also have lesions on her vagina. The patient appears to be in no distress. She is unaware of any exposure to STDs. Patient denies any fever, nausea, vomiting, abdominal pain, cramping, vaginal bleeding, vaginal discharge, diarrhea, constipation, change in stool, or hematuria. She rates pain on exam as 8/10.

Patient provided the HPI as follows:

O – Onset of symptoms 1 wk

L- Vagina

D – 1 wk

C – chancre like lesions

A – any contact with vagina aggravate.

R – No movement or no touching alleviate the pain

T – antiviral medication (Valtrex 1g po BID for 10 days), warm bath, topical lidocaine

S – Rates symptoms 8/10.

Medications:

none

PMH

Allergies:  Denies drug, food, latex, or environmental allergies

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Family History

Mother: Age 48. None

Father: Age 50. Hypertension

Paternal GM: Deceased. Unknown

Paternal GF: Deceased, HTN

Social History

Education Level: High school.

Occupational history: Works in hospitality.

Current living situation: Lives at home with mother.

Substance use/abuse: Denies substance use/abuse.

ETOH: Admits to 5-6 drinks weekly.

Tobacco Use: Never smoked

Safety Status: She states home environment is safe and free from abuse.

ROS

General

Patient denies fatigue, fever, chills. Denies weight change and night sweats. Denies lack of appetite. 

Cardiovascular

 Denies chest pain, palpitations, PND, orthopnea, and edema.

Skin

 Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles.

Respiratory

 Denies cough, wheezing, hemoptysis, dyspnea, pneumonia or TB history.

Eyes

Patient denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma, peripheral visual changes, and dry eyes.
 

Gastrointestinal

Patient denies N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools.

Ears

Denies ear pain, hearing loss, ringing in ears, discharge.

Genitourinary/Gynecological

Denies any urgency, frequency, change in color of urine. Multiple vesicular lesions on labial major and minor.

Last Pap: 2017, normal.

Breast Self-Exam: Admits to conducting breast self-exam monthly.

Mammogram: States she has never had a mammogram.

Menstrual complaints: Denies any menstrual complaints with last LMP.

Vaginal discharge: Denies.

Pregnancy history: Denies any pregnancy history.  Onset of sexual activity with males at age 16, admits to multiple sexual partners and uses contraception, Denies any history of STDs. She reports menarche at age 15.

Nose/Mouth/Throat

Patient denies sinus problems, dysphagia, nose bleeds/discharge, dental disease, hoarseness, and throat pain

Musculoskeletal

Denies back pain, joint swelling, stiffness or pain, fracture history, osteoporosis.

Breast

Denies lumps, bumps or breast changes.

Neurological

Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells.

Heme/Lymph/Endo

Denies blood transfusion history. Denies bruising, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance.

Psychiatric

Denies any sleeping difficulties or suicidal ideations

OBJECTIVE (Document in the Inspection, Palpation, Percussion, Auscultation) format except on Abdomen (IAPP)

Weight:  125 lbs.     BMI: 22.9

Temp: 98.4 F

BP: 120/80 mmHg

Height: 5ft 2 inches

Pulse: 80beats/min

Respirations:  18 breaths/min

General Appearance:

JC is a healthy-appearing well-nourished 20-year-old female in no acute distress. She is alert/oriented x 4 and is dressed appropriate clean clothing.

Skin

Patient’s skin is pink and appropriate to her ethnicity, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is normocephalic and without lesions; hair evenly distributed. No tenderness at facial and maxillary sinuses. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; congested and boggy. No septal deviation. Neck: Supple with full ROM; cervical lymphadenopathy present and palpable; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is non-erythematous and without exudate.

Cardiovascular

S1, S2 with regular rate and rhythm, no clicks, rubs or murmurs. Capillary refill is normal with pulses 3+ throughout. No edema noted.

Respiratory

Respirations regular and unlabored with symmetric chest wall. Lung sounds present and clear to auscultation in all fields. No anterior or posterior crackles/wheezes.

Gastrointestinal

Mildly distended abdomen. Active bowel sounds x 4 quadrants.  Tympanic percussion sounds x 4 quadrants. Non-tender abdomen with palpation x 4 quadrants. No hepatosplenomegaly appreciated on palpation.

Breast

Symmetric, tender, without mass. No swelling, ulceration, or discharge noted.

Genitourinary

Bladder is non-distended; no CVA tenderness. External genitalia without erythema, mases, or lesions noted. No inguinal adenopathy. Multiple vulvar lesions noted. Vagina: mucosa moist and reddened. Small amount of white vaginal discharge noted. Cervix: w/o lesion or mass.  Bimanual exam: denies lower pelvic tenderness, no palpable uterine or ovarian enlargement. Rectum is appropriate; no evidence of hemorrhoids, fissures, bleeding, or masses.

Musculoskeletal

No joint deformities and good range of motion noted as patient moved about the exam room.

Neurological

CN11-X11 intact. Good coordination with normal gait and balance.

Psychiatric

Alert and oriented. Maintains eye contact. Speech is clear and answers questions appropriately. Denies suicidal ideation.

Lab Tests

GC/Chlamydia swab, herpes symplex swab

Special Tests

 None

 Diagnosis

Differential Diagnoses

●       Chlamydia (ICD 10 code A74.9) is a common sexually transmitted infection caused by the bacterium Chlamydia trachomatis (Quinn & Gaydos, 2015). Chlamydia affects the cervix and has no symptoms for 50–70% of women infected (Mardh & Amato-Gauci, 2016). The infection can be passed through vaginal, anal, or oral sex. Approximately half will develop pelvic inflammatory disease (PID), a generic term for infection of the uterus, fallopian tubes, and/or ovaries which causes scarring inside the reproductive organs, which can later cause serious complications, including chronic pelvic pain, difficulty becoming pregnant, ectopic pregnancy, and other dangerous complications of pregnancy (Quinn & Gaydos, 2015).

●       Candidiasis vaginitis (ICD 10 code B37.3) is a vaginal yeast infection that is caused by the organism Candida albican that is a naturally occurring microorganism in the vaginal area. Lactobacillus bacteria keeps its growth in check although if there’s an imbalance in your system, these bacteria won’t work effectively (Martin Lopez, 2015). This leads to an overgrowth of yeast, which causes the symptoms of vaginal yeast infections. Clinically a diagnosis is made by the presence of external dysuria and vulvar pruritus, pain, swelling, and redness. Signs also include vulvar edema, fissures, excoriations, and thick curdy vaginal discharge. This is not supported by clinical & physical assessment.

●       Herpes simplex (ICD 10 code B00.9) is caused by virus infecting the oral or vaginal cavity. The infection may affect one or both. Herpes has two types. With type 1 the infection is spread by oral secretions or sores on the skin, can be spread through kissing or sharing objects such as toothbrushes or eating utensils. Type 2 herpes is spread during sexual contact with someone who has a genital HSV-2 infection. Symptoms are usually acute, with blistering sores (in the mouth or genitals), pain during urination, or itching. Other symptoms include fever, swollen lymph nodes, headaches, tiredness, and decrease in appetite.

Diagnosis

●       Herpes Simplex Virus

Plan/Therapeutics

o    Plan: 

▪          Further testing – None

▪          Medication:  Valacyclovir 1g po Daily x10d

▪          Education: The use of condoms greatly reduces the risk of transmission of STDs. Return to the clinic if worsening of symptoms such as persistent fever, chills, abnormal discharge or other signs of infection otherwise follow up in three months.

▪          Non-medication treatments – None

▪          Follow-up: in one week if symptoms do not clear.

Evaluation of patient encounter: