A Hypothetical SOAP note

Soap note for CC: 16-year-old female c/o of vaginal discharge X 3 days. Write a hypothetical SOAP note based on : LMP- 2 weeks ago, currently sexually active with multiple partners and not using any birth control method. Smokes 10 cigs a day with marijuana on weekends.

1. Write a hypothetical SOAP note based on the above chief complaint.

2. How would you use mnemonic HEEADSSS in history taking with this patient.

3. Document external, internal, bimanual, and rectovaginal PE findings on your SOAP note( See Seidel’s guide page 472, sample documentation).

4. Document Wet Mount result including normal saline and KOH preparation on your SOAP note( See Seidel’s guide page 457).