Write a review of the SOAP note charting.

For each of the following scenarios, write a SOAP note that would adequately reflect the situation, assessment and plan. You do not need to add any more information than what is provided to you in the scenario. For your assessment be sure to include all diagnoses, and at least one differential diagnosis. Each scenario is worth 50 points (100 points total). Please see rubric for grading criteria.

Scenario 1
K.V. has come to the clinic complaining of extreme perineal itching and burning. She reports a white, cheesy-like discharge. Also noted in her history was antibiotic therapy initiated 5 days ago due to an upper respiratory infection. On assessment, lungs are clear, no cough noted, although some nasal drainage is apparent. Pelvic exam shows external genitalia that are reddened. Vaginal exam shows well rugated, reddened vaginal walls and discharge that is thick, white, and cottage-cheese looking. Cervix is closed, mobile, no lesions or cysts, no cervical motion tenderness. Ovarian and uterine exams are normal. Wet prep is positive for yeast, negative for clue cells and trichomonas. Plan is to treat with Diflucan (fluconazole) 150 mg po as a single dose. Patient should return to the clinic if symptoms are not relieved in 5 days. Encouraged warm baths 2x/day and cotton underwear.

Scenario 2
R.G. is 3 months postpartum and calls the on-call CNM with complaints of a temperature of 101 and red, swollen, and tender right breast. She also complains of headache and malaise. Labor and delivery were uncomplicated, she delivered vaginally in the water birth tub and sustained a 1st degree laceration that was not repaired. She is breastfeeding every 2-3 hours and feels the baby drains her breast adequately each feeding. Denies any cracks or bleeding in her nipples. Denies white patches in the baby’s mouth. She denies unusual or foul smelling discharge. No abdominal or uterine pain. The CNM diagnosis is mastitis and orders dicloxacillin 500mg qid x 10 days. She encourages the patient to use warm packs to the affected breast, Tylenol prn for fever and pain, and to continue to breastfeed on the affected side. Patient is to follow up if symptoms are not relieved or significantly better in 5 days.

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