COMPREHENSIVE SOAP NOTE
Comprehensive Soap Note
The following is a comprehensive assessment on a 19-year-old female, G1 T0 P0 A0 L0.
She is of mixed ethnicity, with her mother being white and her father being African
...
COMPREHENSIVE SOAP NOTE
Comprehensive Soap Note
The following is a comprehensive assessment on a 19-year-old female, G1 T0 P0 A0 L0.
She is of mixed ethnicity, with her mother being white and her father being African American.
She is single and still lives with her single mother and her sister.
She comes into today with complaints of vaginal and pelvic pain. The pain has been
going on for several days and is always in the pelvic and vaginal area. The pain starts when she
urinates or when she is having intercourse and describes it as a shooting pain. She reports
aggravating factors such as a vaginal discharge that is constant and describes the color as thick,
mucous and sometimes bloody discharge. She has not using anything or taking anything to
relieve the pain.
According to the patient her last menstrual period was January15, 2016 and using the
Nagele´s rule, which is to add 7 days to the first day of the menstrual period, then subtract 3
months it will calculate the estimated due date, which will be October 22, 2016 (Schuiling &
Likis, 2013).
As far as she knows she was not exposed to Diethylstilbestrol (DES) and neither was her
mother. Diethylstilbestrol (DES) was used between the times of 1940 and 1971 and was used as
an artificial formula of estrogen to prevent miscarriages, preterm labor, and complications during
pregnancy but has been shown to cause clear cell carcinoma (Diethylstilbestrol (DES) and
Cancer, 2011).
She is currently sexually active with males, and is not currently seeing the father of the
baby. She does not use any contraception or protective barrier devices such as female condoms
2
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COMPREHENSIVE SOAP NOTE
or male condoms to prevent sexually transmitted diseases (STDs). She was prescribed Flagyl
500mg bid for 7 days for a positive trichomoniasis vaginal swab earlier in the pregnancy. She
states that she took all the medication but the vaginal exam and the urinalysis reveals otherwise.
The vaginal wet prep reveals small jerky movements made by the trichomoniasis. She denies any
drug use but the urinalysis reveals that she is positive for meth and negative for opioids and
THC.
Trichomoniasis is an STD that is fairly common in the United States with 8 million incidents
yearly. It is a difficult number to attain due to some women being asymptomatic and never
receiving treatment. The numbers are higher among Native Americans at 4.1 % and African
Americans at 6.9 % compared to whites at 1.2 %. Trichomoniasis can cause many adverse events
such as early delivery, premature rupture of the membranes, intrauterine infection, respiratory or
genital infection in the infant, or even cause pelvic inflammatory disease (PID) in women
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