D117 Female Genitourinary SOAP Note Form

Female Genitourinary SOAP Note

Patient Identification

The patient, Maya S., is a 22-year-old female born on January 1, XXXX. She presents today for a routine women’s health examination, which includes her initial comprehensive gynecologic evaluation and cervical cancer screening.

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Subjective Assessment

Chief Complaint

What brings the patient in today?
Maya seeks an annual well-woman visit, which involves her first Pap smear and a full gynecologic examination.

History of Present Illness

What symptoms is the patient experiencing, and for how long?
Maya reports experiencing mild vaginal discomfort over the past two weeks. At rest, she rates the discomfort as 2 out of 10, which escalates to a 6 out of 10 during wiping post-urination. She denies symptoms commonly associated with urinary tract infections such as pain during urination, increased urgency, frequency, or blood in urine. Furthermore, she reports no unusual vaginal discharge, foul smell, fever, chills, or systemic malaise. This visit marks her first Pap smear and gynecologic assessment, indicating no prior cervical screening.

Review of Systems

System	Question	Response
General	Any recent weight changes, fatigue, fever?	Denies weight fluctuations, fatigue, fever, chills, night sweats, or appetite changes.
HEENT (Head, Eyes, Ears, Nose, Throat)	Any vision or hearing changes, nasal symptoms?	Denies visual disturbances, hearing loss, tinnitus, sinus pain, nasal congestion, or smell/taste changes.
Cardiovascular	Any chest pain or palpitations?	Denies chest pain, palpitations, swelling, or arrhythmias.
Respiratory	Any cough, shortness of breath?	No cough, wheezing, or dyspnea reported.
Gastrointestinal	Any nausea, abdominal pain, bowel changes?	Denies gastrointestinal symptoms or changes in bowel habits.
Genitourinary	Any urinary or vaginal concerns?	Denies urinary burning, frequency, urgency, or hematuria. Reports vaginal pain mostly after urination wiping.
Musculoskeletal	Any joint or muscle pain?	Denies joint pain, stiffness, or muscle weakness.
Integumentary	Any skin issues like rashes or itching?	No rashes, pruritus, lesions, or skin discoloration.
Breast	Any breast pain, lumps, or nipple discharge?	Denies breast symptoms or self-exam performance.
Neurological	Any headaches, dizziness, numbness?	Denies neurological symptoms including seizures or sensory changes.
Psychiatric	Any mood or sleep disturbances?	Fully oriented, denies depression, anxiety, or sleep problems.
Endocrine	Any heat/cold intolerance, hair loss?	Denies endocrine-related symptoms such as sweating changes or hair thinning.
Hematologic	Any bruising or bleeding issues?	Denies bleeding disorders or history of transfusions.

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Allergies and Medications

Are there any known allergies?
The patient reports no known allergies to medications, foods, or environmental agents.

What medications is the patient currently taking?
She takes levothyroxine (Synthroid) 75 mcg daily for hypothyroidism, with no adverse effects reported.

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Immunization History

The patient is uncertain about her adult immunization status but recalls receiving vaccinations during childhood. This suggests a need to review and update immunizations, especially the human papillomavirus (HPV) vaccine, which is critical for cervical cancer prevention (American College of Obstetricians and Gynecologists, 2023).

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Past Medical History

The only significant past medical condition is hypothyroidism, which is medically managed with levothyroxine.

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Gynecologic and Obstetric History

Menstrual History

What is the patient’s menstrual pattern?

Parameter	Description
Last Menstrual Period	January 21
Cycle Length	26–28 days
Duration of Flow	Approximately 5 days
Age at Menarche	12 years

Maya reports regular menstrual cycles, indicating normal hormonal function and ovulatory cycles.

Obstetric History

She is gravida 1, para 0, with one prior miscarriage and no living children.

Screening History

Maya has never undergone cervical cancer screening (Pap smear) or mammography, consistent with her age and this being her first gynecologic visit.

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Sexual History

When did sexual activity begin, and what are current practices?
Maya has been sexually active since age 17 and has had two male sexual partners in total. Her current relationship spans four months, with inconsistent condom use reported. She is not using any contraception, which increases her risk for unintended pregnancy and sexually transmitted infections (STIs) (Centers for Disease Control and Prevention, 2022).

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Surgical History

The patient denies any previous surgeries.

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Family History

Family Member	Medical Condition
Paternal Grandparent	Hypertension
Maternal Grandmother	Breast cancer (treated with chemotherapy)

Maya has undergone genetic testing due to her maternal grandmother’s breast cancer history, reflecting awareness of hereditary cancer risk factors.

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Social History

She consumes about one glass of wine weekly, denies tobacco, vaping, or recreational drug use. Maya is independent in daily activities and demonstrates appropriate insight and judgment.

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Objective Assessment

Vital Signs

Measurement	Value
Blood Pressure	108/68 mmHg
Heart Rate	78 beats per minute
Respiratory Rate	16 breaths per minute
Temperature	98.7°F
Height	5 ft 2 in
Weight	54.9 kg (121 lb)
Body Mass Index (BMI)	22.1 kg/m²

All vital signs are within normal limits, and BMI falls within a healthy range.

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Physical Examination

General Appearance

Maya is well-developed, well-nourished, alert, and not in any acute distress.

Skin

The skin is warm, intact, with no visible lesions, rashes, or discoloration.

Head, Eyes, Ears, Nose, and Throat

Her head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Sclerae are clear. Tympanic membranes appear intact bilaterally. Nasal passages are patent, and oral mucosa is moist with good dentition.

Neck

The neck is supple, trachea is midline, and the thyroid is symmetric, non-enlarged, and moves with swallowing without nodules or tenderness.

Cardiovascular

Heart sounds are regular, with no murmurs, rubs, or gallops detected.

Respiratory

Lungs are clear bilaterally with normal chest expansion and no abnormal sounds.

Gastrointestinal

Abdomen is soft, non-tender, and non-distended, with active bowel sounds and no hepatosplenomegaly.

Breast Examination

Breasts are symmetrical with no masses, skin changes, nipple discharge, or lymphadenopathy.

Genitourinary

Inspection reveals erythema and irritation of the external genitalia, with multiple vesicular lesions noted on the vulva, labia majora, and labia minora. Cervical examination shows erythema and bilateral vesicular lesions, raising suspicion for herpes simplex virus infection.

Extremities

No edema, cyanosis, deformities, or varicosities. Gait is steady.

Neurological

The patient is alert and oriented to person, place, and time, with normal speech and a cooperative demeanor.

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Procedure Note: Pap Smear and Pelvic Examination

After obtaining verbal informed consent with a female chaperone present, the patient was positioned in the lithotomy position. The external genitalia showed no masses or tenderness aside from irritation. A lubricated speculum was used to visualize the vaginal walls and cervix. Cervical cytology samples were collected via cytobrush, and vaginal secretions were taken for laboratory analysis. Bimanual examination revealed a midline, smooth, mobile, and non-tender uterus, with no adnexal masses or tenderness noted. The bladder was not distended. The patient tolerated the procedure well.

Post-procedure counseling included advice on potential mild spotting or discomfort for one to two days and instructions on when to seek medical attention if symptoms worsen.

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References

American College of Obstetricians and Gynecologists. (2023). Well-woman visit. https://www.acog.org

Centers for Disease Control and Prevention. (2022). Sexually transmitted infections treatment guidelines. https://www.cdc.gov

D117 Female Genitourinary SOAP Note Form

Hacker, N. F., Gambone, J. C., & Hobel, C. J. (2020). Hacker & Moore’s essentials of obstetrics and gynecology (6th ed.). Elsevier.

U.S. Preventive Services Task Force. (2018). Cervical cancer: Screening. https://www.uspreventiveservicestaskforce.org