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Ob Gyn Soap Note

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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Michelle Tanzil
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6K views1 page

Ob Gyn Soap Note

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.

Uploaded by

Michelle Tanzil
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on 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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