SOAP Note 1
Maria Rodriguez
Age: 25 y.o.
Ethnicity: Hispanic
Past Medical history: None
Past Surgical History: Tonsillectomy age 7
Medications: none
Family history: Mother Diabetes, Father Hyperlipidemia
Employment: works as a phlebotomist full time
S: Maria is an established patient who presents to office today for birth control. Pt is in a monogamous relationship with her current boyfriend of 4 months and is using condoms 100% of the time. Pt would like to start a more reliable form of birth control. Menarche 12 y.o menses: every 28 days and lasts for 5 days, patient denies cramps or irregular menses history. Patient is a non-smoker and does not use any substances. Last pap was 6 months ago negative for cytology. Gonorrhea and Chlamydia culture 6 months ago was neg/neg. HPV vaccine completed.
O: 5 feet 6 inches 140 pounds 98.4-80-16-122/76
General: Healthy appearing Hispanic woman in no apparent distress
Skin: No skin lesions identified
Head: Normocephalic, good hair distribution, no alopecia no nits
Eyes: Symmetrical with no erythema or discharge. Vision grossly normal
Ears: Symmetrical with gross hearing intact
Nose: midline, no septal defect, no discharge
Mouth: good dentition, moist mucous membranes
Cardiac: HR 80 normal sinuses rhythm, no S3 or S4, no arrhythmias noted
Lungs: Clear to auscultation bilaterally A & P, no use of accessory muscles
Abdomen: flat, soft, non-distended. Bowel sounds active in all 4 quadrants, tympanic throughout, no hepatosplenomegaly, no rebound or guarding.
A: Contraception Counseling
P: Diagnostics up to date
Education: During the 20-minute face-to-face visit, I discussed with patient the various forms of contraception including barrier, hormonal, non-hormonal, abstinence and natural family planning. Assignment help – Discussed efficacy, cost, risks and benefits of each method, using the Birth control option handout. Assignment help – Discussed timing to start method and how to use method to ensure efficacy. Patient decided to start oral contraceptives. Assignment help – Discussed Sunday start, daily dosing, missed pills, common side effect and major side effects, such as ACHES and when to call.
Continue Condom use for STD prevention
Pharm: Ortho-Tricyclen 28 day, 1 pill every day to start on Sunday after first day of menses. 3 refills
Referrals: none
Follow- up: 3 months
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