Sims - 7440 – SOAP Note #3 –
Subjective Data:
CC: 27 yr old black female presents to the clinic on 9/20/12 for yearly pap exam.
HPI: the patient states last menstrual period was 8/27/12- last pap exam was in June 2011
PMH: Allergies: NKA
Current Medications include: Metformin 500mg one tablet by mouth daily, Adipex –P 37.5mg
one tablet by mouth daily
History of thyroid disease at age 16, took thyroid meds for 3 months and was taken off by her
physician
Previous Surgeries: Tonsillectomy at age 13
FH: Breast cancer (mother), Hypertension (maternal grandmother), Diabetes (maternal
grandmother), CVA (maternal grandmother)
SH: the patient is married and lives with spouse, denies tobacco, alcohol or drug use, highest
level of education is 12 years, currently working full time, sexually active and using condoms
ROS:
Genitourinary: denies urinary problems or vaginal discharge, denies any irregular periods
Integument: denies any breast pain or lumps
Objective:
27 yr old black female presents to clinic for yearly pap exam
Vital Signs: 98.9 oral, Resp – 18, P-68, BP- 132/66, O2sat 99% on RA, Wt- 268 lbs, Ht – 63 in,
BMI – 47.5 kg/m2
General: Alert and oriented x3, no acute distress noted, appearance is neat and clean
Integument: breast were pendulous, appearance of breast was normal, nipples showed no
abnormalities, no redness or excoriation of the nipples, no inflammatory mass beneath the
nipples, no piercing noted- no abnormal breast secretion was observed, no dimpling noted, no
peau d’organe was noted, palpation of the breast revealed no abnormalities, no mass noted, no
tenderness, no tender nodule of the areola was noted
Genitalia: Vulva was normal, no vulva ulcers or mass noted, labia showed no abnormalities,
clitoris was normal, bartholin’s glands were normal with no abscess noted, Skene’s gland was
not inflamed, no condyloma latum of the female genitalia was noted, no vesicle on the external
genitalia was noted, no piercing noted
Vagina: vaginal discharge of curds was observed, mucosa was not erythematous, no dryness
noted, no vaginal ulcers, vesicles, or masses noted, no rectovaginal fistula was observed, no
uterine prolapsed, no lacerations noted, no foreign body noted
Pelvic: no ovarian tenderness
Cervix: pap smear was taken, no cervical discharge, no lesions or ulcers noted, no polyp or cyst
was noted on the cervix, did not demonstrate any tenderness or pain elicitated by motion, no
cervix friable
Uterus: no tenderness noted, no mass noted
Uterine Adnexae – uterine adnexa was not tender – no tubal mass was noted
Rectovaginal: tissue was normal
Rectal: normal exam – no mass noted
Treatment:
Diagnostic test performed and results:
1) Pap smear was sent to reference lab
2) Nucleic acid amplified probe technique for Chlamydia trachomatis was sent to reference
lab
Assessment:
Acute Diagnosis:
1) Routine gynecological exam with cervical pap smear
2) Bacterial Vaginosis
Chronic Diagnosis:
1) Obesity – patient is currently taking Adipex-p 37.5mg and Metformin 500mg for weight losspatient has been taking meds for 3 months and has lost 10 lbs.
Education:
Discussed with patient:
1) Importance of self breast exam
2) Yearly pap exam
3) Sexually transmitted diseases
4) Birth control
5) Diet and exercise
6) Weight loss
Plan:
1) Flagyl 500mg one tablet by mouth every 8 hours for 7 days dispense 21 tabs no refills,
Diflucan 150mg tablet one tablet by mouth if needed for yeast infection may repeat in 3 days if
needed dispense 2 tablets no refills.
2) Follow up in 1 year for re-examination or sooner if needed, will contact patient if any
abnormalities are found with lab results