Write 15 different visit notes for reproductive health care notes on women wellness care
*Each entry includes Subjective , Objective, Assessment, Practice management, Diagnosis, Procedures (if applicable), Treatment plan and notes, Notes section (Students must include a brief summary/synopsis of the patient visit—this must include enough information to understand how the patient presented and the student intervention. Do NOT include EMR SOAP notes
May choose on any of the followings or other women visit note : Osteoporosis, Pelvic inflammatory Disease; Contraceptive Management; IUD placement; IUD removal; Vaginal discharge; Vaginal Atrophy; Vaginitis; Trichomoniasis; Candidiasis; Chlamydial infection; Pregnancy; Irregular Menstruation; Amenorrhea; Dysmenorrhea; Endometriosis; Menopause; Bleeding all types; Routine normal Pap Smear; Abnormal Pap Smear; Annual gynecology exam; Well woman exam; Infertility;
Example: J.S. is a 25-year-old woman with no significant past medical history presenting to the clinic with complaints of increased vaginal discharge and a strong “fishy” odor for the past week. She denies any associated pain, fever, or systemic symptoms. The patient reports occasional itching but no burning sensation during urination. She has been sexually active with one male partner for the past year and uses condoms inconsistently. She recently started using scented feminine hygiene products. V/S: T 98.6°F, P:72 bpm, RR:16, B/P: 118/75; Wt.: 150 lbs. Physical examination showed a patient in no form of distress. Pelvic examination reveals thin, grayish-white vaginal discharge coating the vaginal walls without significant erythema or lesions. There is no adnexal tenderness or cervical motion tenderness.
Whiff test is positive, and vaginal pH is elevated to 5.2. Microscopy of the vaginal discharge shows clue cells, with no evidence of trichomonads or yeast.
Diagnosis: Bacterial Vaginosis (BV).
Assessment: Increased vaginal discharge with a strong odor, elevated vaginal pH, positive whiff test.
Plan:
1. Prescribe oral metronidazole 500 mg twice daily for 7 days
2. Informed patient the importance of completing the course of antibiotics.
3. Patient was informed to avoid scented feminine hygiene products, douching, and other irritants.
4. Emphasize to patient, the importance of consistent condom uses to reduce risks
5. Return to the clinic if symptoms persist or worsen after completing the course of antibiotics.
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