SOAP Note Blue Print Course: 7602 FNP 1 Student: Gangagowri Saravanakumar Faculty: Dr. Powell Pt Initials: CS Age: 69 years Race: Caucasia n Sex: Femal e New Pt: Established Pt: x Info Source: patient Reliability: good E&M Code(s) 99213 S CC: Vaginal itching and irritation HPI: A 69 years old Caucasian widow presents to office today with c/o vaginal itching and irritation, dysuria. She reports her symptoms started 2 weeks ago, describes pain as severe burning pain to the vulvo vaginal area with urination, score of 8, aggravated with urination, does not radiate anywhere, associated with white vaginal discharge, scant amount, on & off, nocturia and urge incontinence. She states she tried monistat OTC application for the vaginal itching and irritation with no relief. She reports not taking any medication for pain. Hist ories : PMH: right Breast cancer, removal of left lymph nodes, HTN, Osteoporosis Ob/GYN history: G2P2A0L2, 2 daughters (45 years old and 40 years old), SVD, menarche at 13 years, menopaused at 52 years age,
You've reached the end of your free preview.
Want to read all 3 pages?
- Fall '08
- estrogen, Vagina, Candidiasis, vaginal itching