Student’s Name: Date: Age: 25 Date of Birth: 03/06/1999 Gender: Female Comment: Ethnicity: Hispanic SUBJECTIVE DATA Chief Complaint (CC) I’m experiencing a persistent yeast infection in the vaginal area since my last transvaginal ultrasound a week ago History of Present Illness Read More
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Student’s Name: Date:
| Age: 25
Date of Birth: 03/06/1999 |
|
| Gender: Female Comment:
|
Ethnicity: Hispanic |
SUBJECTIVE DATA
| Chief Complaint (CC)
|
I’m experiencing a persistent yeast infection in the vaginal area since my last transvaginal ultrasound a week ago
|
| History of Present Illness (HPI)
**GYN Focus**
|
presents for a routine OB visit. She reports a persistent yeast-like infection in the vaginal region since her last transvaginal ultrasound one week ago. Symptoms include itching, white discharge, and a burning sensation. She initially tried Monistat, but it provided little relief and caused side effects such as shaking, chills, and an increased burning sensation.
Must include Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing, and Severity (OLDCARTS). Include pertinent positives from the review of systems as they relate to the HPI. |
| OB/GYN history
|
G2P1001. LMP 09/17/2024. Last PAP 04/09/2024 WNL
Mammogram: N/A
|
| Sexual History |
History of STD, last sexual partner, sexual history, birth control hx, sexual orientation, |
| Past Medical History (PMH)
|
In chronological order: Current/Past medical problems with date of onset |
| Past Surgical History (PSH)
|
In chronological order: Surgeries and Procedures with date performed and outcome |
| Immunization status
|
Age specific immunizations, list and describe any history of reactions |
| Medications
**birth control** |
Current medications: include medication name, dose, route, frequency, duration, and reason for taking |
| Allergies |
Medications, Foods, Environmental, Latex and how allergy is manifested |
| Family History (FH) |
Blood relatives: Age, living/deceased, medical problem. Include grandparents, siblings, children |
| Social History (SH) |
(marital status, children), Lifestyle risk factors (illicit drug use, smoking/pack year, exercise) , Employment history, Education, Religion – beliefs, Cultural history, Support System, Stressors, Driving |
| Review of Systems
(ROS) |
|
| Constitutional |
General statement by the patient (reported symptoms that do not fit one system but often affect overall status) |
| Skin
|
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| Eyes, Ears, Nose Throat/Mouth
|
|
| Cardiovascular
|
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| Respiratory
|
|
| Gastrointestinal
|
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| Reproductive / Genitalia / Genitourinary |
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| Breast/Lymphatics | |
|
Musculoskeletal
|
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| Neurological
|
|
OBJECTIVE DATA
| Physical Exam | |
| General/Constitutional |
General description of patient including age, gender, nutritional status, habitus, attention to grooming, state of cooperativeness/demeanor, overall picture of wellness/distress |
| Vital Signs
|
Temperature, Pulses (apical and radial), Respirations, BP (Ht, Wt, BMI) |
| Skin
|
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| HEENT
|
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| Neck
|
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| Respiratory
|
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| Cardiovascular
|
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| Breast/Lymphatics
|
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| Abdomen
|
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| Female Genitourinary/
GYN
|
Vulvar Exam:
Speculum Exam: · Cervical Exam: Bi-manual Exam:
(Describe all assessment findings for each portion of the GYN exam, if portion of exam was not one- please document “deferred”) |
| Rectal
|
Rectal Exam:
|
| Musculoskeletal
Including frailty evaluation if applicable
|
|
| Neurological |
(Mental Status, Cranial nerves, Motor, Cerebellum, Motor, Cerebellum, Sensory, Reflexes) |
| Diagnostic Information |
Results of diagnostic testing conducted at the time of the visit OR previously done and being used to support the diagnosis and management plan for the current visit |
DIFFERENTIAL DIAGNOSES AND SUPPORTING DATA
| 3 differential diagnoses | Data in your assessment that supports or rules out this diagnosis |
|
|
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Final ICD 10 diagnosis codes for the current visit
| ICD 10 Code | Corresponding Diagnosis |
| 1.
|
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| 2. |
|
| 3.
|
|
| 4.
|
|
| 5.
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TREATMENT PLAN
(Include rationale for all components of treatment plan and support with citations from peer-reviewed information)
| Additional Diagnostic tests needed
|
|
| Treatments: Pharmacological |
|
| Treatments:
Non-Pharmacological |
|
| Patient Education |
|
| Consultations recommended with
Rationale |
|
| Return to Clinic/Follow-Up |
Next office visit scheduled, identify the plan for follow-up, note expectations for further treatment. |
CPT Billing Codes Reflected in the Treatment Plan
| CPT Code | Corresponding Diagnosis |
| 1.
|
|
| 2.
|
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| 3.
|
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| 4.
|
|
| 5.
|
| FNP Student
West Coast University
Patient Name _____________________________________ Date ___________________
|
| Rx
Refill NR 1 2 3 4 5
Signature ____________________________________________________________ |
Discussion: (for Problem-focused SOAP notes ONLY)
Please provide a 1-2 paragraph discussion on your case. This can be why you chose the specified/prescribed treatment plan, the pathophysiology of the assessment, why you referred the patient for a specific diagnostic test, etc.
References: Please use at least three current (within 5 years) guidelines, articles, or textbook. Please list.
Evan John