Question

i need an example of a soapnote for ob/gyn--about uterine bleeding or PID

Answer 1

SOAP Notes

Subjective, Objective, Assessment, Plan*

1. Subjective

-patients complaint and anything they tell you

2. Objective

-findings, completed testing results (not pending)

3. Assessment

-diagnosis (symptoms if diagnosis isn't available) suspected diagnosis

4. Plan

-treatment, patient education

SOAP note for PID :-

1. Subjective :-

Patient complaints of :-

Low-grade fever

Malaise

Lower abdominal pain, worsening with intercourse

Irregular vaginal bleeding

Nausea and vomiting

2. Objective :-

Patient has :-

Bilaterally tender adnexal mass

Profuse, purulent vaginal discharge

Rebound tenderness, involuntary guarding (suggestive of peritonitis)

3. Assessment :-

Diagnosis of PID confirmed by the following tests :-

Culture and sensitivity and Gram stain of endocervix or cul-de-sac secretions show the causative agent.

Transvaginal ultrasonography may show the presence of thickened, fluid-filled fallopian tubes.

Computed tomography scan may show complex tubo-ovarian abscesses and is useful in diagnosing PID.

Magnetic resonance imaging provides images of soft tissue; useful not only for establishing the diagnosis of PID but also for detecting other processes responsible for symptoms.

4. Plan :-

Treatment of PID

Patients often need to be hospitalized

Antibiotics include broad-spectrum cephalosporins like cefoxitin or cefotetan, and doxycyclin

Clindamycin and gentamicin can be used if patient is allergic to cephalosporins

Surgery to drain abcess

#.Patient education :-

- maintain hygiene

- compliance to medications

- avoid intercourse

- healthy diet

- monitor side effects of antibiotics