Soap note for Herpes simple genital.
Make a soap note for each case provide.
| Other Questions About This Case | |
| Nutritional Status: | Good |
| Smoking Assessment: | Non-smoker |
| Trimester: | |
| Patient’s primary language: | Spanish |
| Ethnicity: | Spanic/Latin |
| History of present illness (HPI): | 29 y/o female who comes because she ahs a lesion in her vagina |
| Other current meds/herbals/vitamins: | no |
| TIme spent performing family assessment: | 5 min |
| Blind : | |
| Deaf: | |
| Screen for drugs: | Yes |
| Screen for alcohol: | Yes |
| Homeless: | |
| Religious practices affecting care: | |
| Immunizations up to date: | Yes |
| Patient is non-ambulatory: | |
| Patient is ambulatory: | |
| Antepartum new: | |
| Peri/postmenopausal visit: | |
| Breastfeeding eval and counseling: | |
| Early postpartum visit < 1 week: | |
| Home birth: | |
| Newborn assessment: | |
| Clinical Notes | |
| CC:” I have itchy and vesicular in my private parts” HPI: 29 y/o Hispanic female who comes to the clinic today because of a painful, itchy rash in her vagina. Patient refers that the initial symptoms was a painful sensation with skin lesions and 2day ago the vesicular lesions appear in the same site and now she has itchy and the pain is table with minimal relive with Tylenol or ibuprofen. Patient states no rash in other body part, denies any fever, or cough. Patient denies previous treatment for recently or old STD. Denies weight change. PMH: healthy. Vaccination up to date. NKA Medication: Tylenol 500 mg as needed for the pain Ibuprofen 200 mg 400 mg q 6h as needed for pain. Vital signs: BP: 110/67, HR: 67, RR: 18, Temp: 98.0 pain: 7/10 now. ROS: General: The patient denies any memory problems, no headache, denied visual, or hearing loss, or reading glass use, denies tingling, or numbness, no muscle weakness, or walking problems. Pt states no walking problems. Denies dizziness or vomiting. HEENT: Pt Denies any ear, eyes, or neck pain. No visual or hearing changes. Pt states no nasal secretion denies nose bleeding, or tooth pain, refers no swallowing, or chewing problems. She states good smell and sense of taste. Pt denies Thyroid problems. Cardiovascular: Pt denies, and denies chest pain, shortness of breath, or leg pain. No skin color change. No edema, no cyanosis. Peripheral pulse presents and 2+. Respiratory: Pt denies shortness of breath, or cough, or chest pain. No sputum production. GI: Pt denies any retrosternal pain, no nausea or vomiting, no diarrhea, no blood in the stool, denies constipation and state regular daily BM. GU: Patient denies dysuria during or Nycturia and even he denies blood in urine. Pt states no vaginal discharge and states regular and normal bleeding during the menstrual periods but states vaginal vesicular and itchy. Musculoskeletal: No painful walking and no muscle weakness. Spine with no problems. Skin: Patient refers painful, itchy, vesicular rash in the upper back. Physical exam: General: Pt came with normal walking and appearance, well-groomed and dressed, alert, and oriented to time, person, place and situation, normal speech. HEENT: head normal, normal hair implantation and distribution, for the age, ear normal implantation with no pain at palpation, no drainage, normal tympanic membrane. Nasal mucosae red and congestive and clear discharge notice coming from the nares, no pain on pressure over the frontal and maxillary sinus. Normal eyes, no nystagmus, PERRLA, normal eyes movements in all quadrants. Neck flexible, no mass, no nodules, thyroid no visible not palpable. Cardiovascular: Normal external chest appearance, no thrill, S1S2, no abnormal sounds. peripheral pulse 2+ Respiratory: Normal external chest appearance and expansion, no fremitus, and normal pulmonary sound in all pulmonary areas. abdomen, soft, flat, normal bowel sound in all quadrants, no pain to light, or deep palpation. kidneys no palpable. CVA no painful to percussion. GU: No discharge but external genital and anus covered by vesicular with clear liquid and redness. Musculoskeletal: Normal upper and lower extremities, respond to commands and against resistance spine normal, normal articulation. Normal gait, no ataxia. No Painful movements to walk and no inflammation noticed. Spine normal, no scoliosis. Skin: vesicular lesions in the introit and external genital and anus. Nails intact, and normal hair distribution. Neurology: Patient with a normal gait, alert and oriented to person, time, place and situation, normal speech, and written. superficial and deep tendon reflexes normal. Normal light and deep sensation, hyperesthesia in the left upper side of the back. Stereognosis, graphesthesia normal. No Babinski. No ataxia, normal gait. Cranial nerves: I normal; II (tested with the reading glasses) normal; III, IV, VI, normal; V normal; VII normal; VIII Normal; IX normal; X normal. XI normal, XII normal. Diagnostic: Herpes simple genital Plan: Ibuprofen 200mg 2tab as needed for pain. Acyclovir 400 q 4h x10 days. Acyclovir cream every 3 hours x 7 days. |
This one is the 2nd case log for the second Soap note;
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| Procedures/Skills (Observed/Assisted/Performed) | |
| General Skills – Breast exam (Asst) General Skills – Immunizations (Asst) General Skills – Interpret lab studies (Asst) General Skills – Pap smear (Asst) General Skills – STD & HIV screening/counseling (Asst) |
| ICD-10 Diagnosis Codes | |
| #1 – | Z30.8 – ENCOUNTER FOR OTHER CONTRACEPTIVE MANAGEMENT |
| #2 – | Z01.419 – ENCNTR FOR GYN EXAM (GENERAL) (ROUTINE) W/O ABN FINDINGS |
| CPT Billing Codes | |
| #1 – | 99203 – OFFICE/OP VISIT, NEW PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 30-44 MIN |
| #2 – | 2010F – VITAL SIGNS DOCUMENTED AND REVIEWED |
| #3 – | 99071 – PATIENT EDUCATION MATERIALS PROVIDED BY PHYSICIAN/OTHER PROFESSIONAL |
| #4 – | 58300 – INSERTION, INTRAUTERINE DEVICE |
| Birth & Delivery |
| Medications | |
| # OTC Drugs taken regularly: | 1 |
| # Prescriptions currently prescribed: | 1 |
| # New/Refilled Prescriptions This Visit: | 1 |
| Types of New/Refilled Prescriptions This Visit: Analgesic/Antipyretic – NSAIDS |
Adherence Issues with Medications: |
| Other Questions About This Case | |
| Nutritional Status: | Good |
| Smoking Assessment: | Former Smoker |
| Trimester: | |
| Patient’s primary language: | Spanish |
| Ethnicity: | Spanic/Latin |
| History of present illness (HPI): | #0 y/o female who comes today for a IUD insertion |
| Other current meds/herbals/vitamins: | multivitamins |
| TIme spent performing family assessment: | 5 |
| Blind : | |
| Deaf: | |
| Screen for drugs: | Yes |
| Screen for alcohol: | Yes |
| Homeless: | |
| Religious practices affecting care: | |
| Immunizations up to date: | Yes |
| Patient is non-ambulatory: | |
| Patient is ambulatory: | Yes |
| Antepartum new: | |
| Peri/postmenopausal visit: | |
| Breastfeeding eval and counseling: | |
| Early postpartum visit < 1 week: | |
| Home birth: | |
| Newborn assessment: | |
| Clinical Notes | |
| CC: I came for the lab’s review and for an IUD insertion HPI: 30 y/o female who comes today to check the labs for the IUD insertion as birth control.. G3T2P2A1L2. Medication: levothyroxine 125mch daily NKA Viatls BP 120/60 ( manual) HR: 67, RR 19, temp: 97.5 Review of systems: Musculoskeletal: No pain or difficulty walking and no muscle weakness. Spine with no problems. |
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