D117 Female Genitourinary SOAP Note Form

D117 Female Genitourinary SOAP Note Form

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Student Name

Western Governors University 

D117 Advanced Health Assessment for the Advanced Practice Nurse

Prof. Name

Date

Female Genitourinary SOAP Note

Patient Identification

The patient, Maya S., is a 22-year-old woman born on January 1, XXXX. She has come for her annual well-woman visit, which includes her first full gynecologic examination.

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Subjective Assessment

Chief Complaint

What brings the patient in today?
Maya presents for her routine yearly well-woman check-up, which also serves as her initial comprehensive gynecologic exam and first Pap smear for cervical cancer screening.

History of Present Illness

What symptoms has the patient noticed, and for how long?
Maya reports experiencing mild vaginal discomfort for the past two weeks. She rates the discomfort at 2 out of 10 when at rest, escalating to 6 out of 10 during wiping after urination. She denies any typical urinary symptoms such as pain during urination (dysuria), urgency, frequent urination, or blood in urine. There is no abnormal vaginal discharge, foul odor, fever, chills, or general malaise. This is her first cervical cancer screening and comprehensive gynecologic exam, with no prior Pap smear history.

Review of Systems

System	Symptoms Denied	Symptoms Present
General	No weight changes, fatigue, fever, chills, or night sweats	None
Head, Eyes, Ears, Nose, Throat (HEENT)	No vision or hearing changes, no sinus symptoms	None
Cardiovascular	No chest pain, palpitations, edema	None
Respiratory	No cough, wheezing, or shortness of breath	None
Gastrointestinal	No nausea, vomiting, abdominal pain, or bowel changes	None
Genitourinary	No urinary burning, urgency, frequency, or hematuria	Vaginal pain after urination wiping
Musculoskeletal	No joint or muscle pain	None
Integumentary	No rash, itching, or lesions	None
Breast	No breast pain, lumps, nipple discharge	None
Neurological	No headaches, dizziness, numbness	None
Psychiatric	No depression, anxiety, or mood disturbances	None
Endocrine	No heat/cold intolerance, excessive sweating	None
Hematologic	No bleeding or clotting problems	None

Allergies

Maya denies any known allergies to medications, foods, or environmental triggers.

Current Medications

She takes levothyroxine 75 mcg daily for hypothyroidism without adverse effects.

Immunization History

Maya is uncertain about her adult immunization status, recalling only childhood vaccinations. This suggests a need to review and possibly update vaccines, including HPV vaccination if not already administered.

Past Medical History

She has a history of hypothyroidism currently well controlled with medication.

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Gynecologic and Obstetric History

Menstrual History

What is the patient’s menstrual cycle like?

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

Her menstrual cycles are regular, consistent with normal ovulatory function.

Obstetric History

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

Screening History

She has never had a Pap smear or mammogram before this visit, appropriate given her age and first gynecologic visit.

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Sexual History

When did sexual activity start, and what are current practices?
Maya has been sexually active since age 17, with two male partners in her lifetime. She has been in her current relationship for four months and reports inconsistent condom use. She currently uses no contraception, increasing her risk for unintended pregnancy and sexually transmitted infections.

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Surgical History

The patient reports no prior 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, indicating awareness of hereditary cancer risk factors.

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Social History

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

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Objective Assessment

Vital Signs

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

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

Physical Examination

• General Appearance: Maya appears well-developed, nourished, alert, and not in distress.

• Skin: Warm and intact without rashes, lesions, or discoloration.

• HEENT: Normocephalic, atraumatic head; pupils equal and reactive; clear sclera; intact tympanic membranes; patent nasal passages; moist oral mucosa.

• Neck: Supple with midline trachea; thyroid symmetrical and without nodules or tenderness.

• Cardiovascular: Regular heart sounds, no murmurs or abnormal sounds.

• Respiratory: Lungs clear with no abnormal breath sounds.

• Gastrointestinal: Abdomen soft, non-tender, no enlargement of liver or spleen.

• Breast: Symmetrical, no masses or skin changes, no nipple discharge.

• Genitourinary: External genitalia show erythema and irritation with multiple vesicular lesions on vulva and labia. Cervix also shows erythema and vesicular lesions bilaterally, suggesting possible herpes simplex virus infection.

• Extremities: No edema, cyanosis, deformities; gait steady.

• Neurological: Alert, oriented, normal speech, cooperative.

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Procedure Note: Pap Smear and Pelvic Examination

The patient gave verbal informed consent with a female chaperone present. The procedure was explained, including risks and benefits. Maya was positioned lithotomy for examination.

Inspection showed irritation without masses or tenderness. A speculum was inserted to view the vaginal walls and cervix. Cytology samples were collected using a cytobrush, and vaginal secretions were obtained for lab culture. The bimanual exam revealed a midline, smooth, mobile uterus without masses or tenderness, and a non-distended bladder. The patient tolerated the exam well.

Post-procedure counseling covered potential mild spotting and discomfort for 1-2 days and when to seek medical attention.

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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

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

D117 Female Genitourinary SOAP Note Form

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