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  • Ob Gyn Soap Note

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    Michelle Tanzil
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    The patient's pelvic exam showed normal female genitalia without lesions. The vagina appeared pink without loss of texture or lesions. The cervix had a parous opening and was long and closed without lesions. The uterus was enlarged to 10-12 weeks in size, mobile, and tilted forward without masses or tenderness. The adnexa had no masses or tenderness. A rectal exam was not indicated for the patient.

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    The patient's pelvic exam showed normal female genitalia without lesions. The vagina appeared pink without loss of texture or lesions. The cervix had a parous opening and was long and closed without lesions. The uterus was enlarged to 10-12 weeks in size, mobile, and tilted forward without masses or tenderness. The adnexa had no masses or tenderness. A rectal exam was not indicated for the patient.

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    5K views1 page

    Ob Gyn Soap Note

    Uploaded by

    Michelle Tanzil
    The patient's pelvic exam showed normal female genitalia without lesions. The vagina appeared pink without loss of texture or lesions. The cervix had a parous opening and was long and closed without lesions. The uterus was enlarged to 10-12 weeks in size, mobile, and tilted forward without masses or tenderness. The adnexa had no masses or tenderness. A rectal exam was not indicated for the patient.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    HPI:

    Pelvic exam BUSV(bartholins, urethra, skin and vestibule): Normal female genitalia, no lesions Vag: Pink, no loss of rugae, no lesions Cervix: parous os, no lesions, long/closed Uterus: 10-12 wks sized, mobile, NT, ant efflexed Adnexa: no masses, no tenderness Rectal: not indicated (do if >40yo on rectovaginal exam, FOBT done if >50)

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