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SOAP NOTEName:R.M.Date:11/14/2019Time: Age: 24Sex:FemaleSUBJECTIVECC: “Vaginal itching and a greenish discharge”HPI: R.M. is a 24 year old African American female that present to the clinic with vaginal itching and a greenishcolor discharge for just over 2 weeks. Symptoms have increased in severity over the last few days. Urinary and lower abdominal discomfort and urinary frequency started yesterday. Abdominal and urinary discomfort pain scale is a 3 on a pain scale of 1 to 10. Admits to history of chlamydia in the past, 2 sexual partners over the last 2 months and inconsistent condom use. Denies knowledge whether partners have similar symptoms. Denies complaints of fever, chills, sweats, dyspareunia. Medications: Junel PMH G:1, T:0, P:0, A:1, L:0Miscarriage 7 weeks gestation Allergies: NKDAMedication Intolerances: N/A1
Chronic Illnesses/Major traumas: N/AHospitalizations/Surgeries (include delivery of pregnancies here):G:1, T:0, P:0, A:1, L:0Family HistoryFather: Unknown Mother: 40 y.o. AL&WBrother: 22 y.o. AL&WBrother: 23y.o Al& WSister: 18 y.o. AL&WSister:15 y.o. AL&WSocial HistoryCurrently works full-time at Walmart as a cashier and attends college part time at Olive-Harvey College. Does not currently have a steady boyfriend but have 2 sexual partners and does not use condoms consistently. Does not have knowledge whether partners have other sexual partners and whether condoms are used. Had a miscarriage 3 years ago and started birth control pills after that. Admits to smoking marijuana sometimes. Drinks alcohol with friends once a week and consumes about 2 – 3 glasses. Denies history of tobacco smoking, heavy drinking, or other illegal drug use.