Gynecology SOAP Note Sample Report #1
SUBJECTIVE: This is a pleasant (XX)-year-old nulliparous female who presents today with a chief complaint of amenorrhea for approximately four months as well as intermittent pelvic cramping for the past six weeks. She was last seen by me on (XX) for a repeat Pap smear. Her Pap smear at that time was negative for malignancy. She was originally seen by me in January for a routine gynecologic exam. Pap smear was unsatisfactory. Human papilloma virus DNA test was positive. The patient was cycling on Kariva birth control since her January visit. She was unable to come to her followup pill check and repeat Pap smear until (XX) as she was traveling for work in the spring. She ran out of her birth control pill and discontinued taking it in June. She was seen on (XX). A prescription was filled at that point. She restarted the birth control pill in mid July, had a period soon thereafter, a four-day flow which was irregular for her and somewhat painful. She cannot recall the exact dates. She stopped taking the birth control pill as she thought the irregularity was due to being on the pill and has since then not had her periods. Reports being sexually active since that time, using condoms “most of the time”. She has not taken a home pregnancy test. Complains of intermittent generalized pelvic cramping for the past six to seven weeks. She also reports some clear nonodorous discharge as well as some bladder pressure. Denies dysuria, painful urination or issues with bowel patterns. Reports that her weight has been steady.
REVIEW OF SYSTEMS: Denies any nausea or hypersensitivities to smell.
PAST MEDICAL/SURGICAL HISTORY: Type 1 diabetes, heart murmur, and history of migraine headaches with menses.
MEDICATIONS: Humulin; uses an insulin pump.
ALLERGIES: Reglan.
FAMILY HISTORY: Positive for colon cancer in father diagnosed at age 65, and negative for breast and ovarian cancer.
SOCIAL HISTORY: Currently sexually active in a monogamous relationship for the past year. Denies domestic safety concerns. Works as a (XX) at (XX). Nonsmoker. Occasional ETOH. Intermittent exercise.
OBJECTIVE: General: This is a well-appearing (XX)-year-old in no acute distress. Height 5 feet 7 inches. Weight 184 pounds. Blood pressure 110/70. Pain score 2 out of 10, related to pelvic cramping. Abdomen: Soft, nontender to palpation. No hepatosplenomegaly or masses palpated. Pelvic exam revealed normal female external genitalia, urethra, and vagina with skin intact and no lesions noted. Internal exam revealed vaginal vault with moderate amounts of milky white discharge, odorous, and consistent in findings with Gardnerella infection. Vaginal profile obtained for yeast and Gardnerella. Cervix well visualized. Bimanual exam: No CMT. Uterus is somewhat enlarged and anteverted. Adnexa negative.
ASSESSMENT AND PLAN: Amenorrhea for four months. Rule out pregnancy. Beta-hCG was ordered. We will notify the patient via cell phone when the results are in. Appropriate contact information would be provided for services outside of this clinic. If beta-hCG is negative, we will order a pelvic and transvaginal ultrasound to evaluate lining and possibly perform progesterone challenge test. She will be following up with me in (XX) for a routine annual.
Gynecology SOAP Note Sample Report #2
SUBJECTIVE: The patient is a (XX)-year-old nulliparous woman with an LMP on (XX), who came for followup Pap smear. In June (XX), her Pap smear showed HSIL, and in October (XX), she had excisional biopsies by colposcopy, which proved to be CIN-3. The patient had a colposcopy exam in April, which was normal and her Pap smear was normal at that time as well. She is having no unusual discharge or dysuria, and she has had no change in sexual partner. She is on Kariva which has helped her headaches, but she does sometimes feel some moodiness towards the end of the pack.
OBJECTIVE: General: The patient is a healthy-appearing (XX)-year-old. Vital Signs: Height 5 feet 3 inches, weight 134 pounds. Blood pressure 116/66. Pain score 0. Pelvic: Vulva: No lesions. Vagina: No discharge. Cervix: Nulliparous. Uterus: Anteverted, mobile, normal size. Adnexa: Within normal limits. A Pap smear was obtained.
ASSESSMENT: History of CIN-3 with excisional biopsies.
PLAN: We will write to the patient with the result of her Pap smear, and if it is less than or equal to LSIL, we will see her in 6 months for her complete gynecologic exam.
