Focused Soap Note

To prepare:

  • Use the Focused SOAP Note Template provided to complete assignment.
  • With this patient in mind, address the following in your Focused Note Template:

Assignment:

  • Subjective: What details did the patient provide regarding her personal and medical history?
  • Objective: What observations did you make during the physical assessment?
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
  • Reflection notes: What would you do differently in a similar patient evaluation?

 

 

Patient Scenario- 30 year old female in office for yearly exam. Patient complains of vaginal itching. Urinalysis and pelvic exam performed. Patient urinalysis normal. Cultures obtained this visit. Last pap smear 2019 which was normal. Wet prep with positive whiff test and clue cells. Patient treated for BV with Metronidazole 500 mg PO BID x7 days. Patient to return in 1 year or as needed. No surgical history or pertinent medical history. No medications. Allergic to shellfish.

 

Need 3 differential diagnosis.

 

Please provide scholarly articles as references to support information for assessment, plan, diagnosis and reflection notes.

 

Please make up any additional information needed

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