Please create 5 mini GYN SOAP Notes

Please create 5 mini GYN SOAP Notes


CC: “I am here for a follow up of chronic left sided pelvic pain.”

S: 34-year-old African American female here for follow up for chronic left sided pelvic pain. G3P1 with LMP 1 week ago. Patient first seen 5 months ago with complaints of pain x 2 years. She describes pain as dull and aching, intermittent, with no relationship to eating but increased before and during menses. Pain has gotten worse over the last 5 months and requires her to miss work 2-3 days per month. No relief with NSAIDs. Patient has history of chlamydia 5 years ago for which she was treated. No history of PID. Three partners within the past year: no condom use. No GI symptoms: regular BMs, no constipation, diarrhea, nausea or vomiting. History of ectopic x 2 with removal of part of the left and right tubes. Also had ruptured appendectomy at age 20. On birth control pills for contraception.

O: Vitals: BP: 128/ 89, HR: 92, RR: 22, Temp: 99.3; W: 194, H: 5’6, BMI: 32.0.

A: Abdomen: 1+ LLQ tenderness, no peritoneal signs Pelvic: Ext genitalia: Normal. Vagina: no discharge. Cervix: no lesions. Biman: uterus small, retroverted, NT, 3+ left adnexal tenderness, no right adnexal tenderness, and no masses palpated. Pelvic pain unresponsive to medical management treatment.

Differential Diagnosis: Endometriosis, Adhesive disease, PID P: Labs: CBC count and sedimentation rate, Serum drug screen, Urinalysis and urine culture, STD tests, Follicle-stimulating hormone level, estradiol level, and gonadotropin-releasing hormone agonist stimulation, TSH: all pending Special testing: Schedule diagnostic laparoscopy.

Medication: None prescribed at this time.

Education: Discussed diagnostic laparoscopy procedure and anesthesia with patient. Follow the instructions exactly about when to stop eating and drinking, or your surgery may be canceled. If your doctor has instructed you to take your medicines on the day of surgery, please do so using only a sip of water. Leave your jewelry at home. Arrange for someone to drive you home after the laparoscopy. Follow-up: RTO in one week for test

Complete Answer:

Get Instant Help in Homework Asap
Get Instant Help in Homework Asap
Calculate your paper price
Pages (550 words)
Approximate price: -
Open chat
Hello 👋
Thank you for choosing our assignment help service!
How can I help you?