D117 Female Genitourinary SOAP Note Form

D117 Female Genitourinary SOAP Note Form

Student Name

Western Governors University

D117 Advanced Health Assessment for the Advanced Practice Nurse

Prof. Name:

Date

Female Genitourinary SOAP Note

Patient Identification

Name: Maya S.
Date of Birth: January 1, XXXX

Subjective Assessment

Chief Complaint

The patient presents for an annual women’s health visit and her first gynecologic examination, including a Pap smear.

History of Present Illness

Maya S. is a 22-year-old female presenting for her initial gynecologic and cervical cancer screening visit. She reports experiencing vaginal discomfort for approximately two weeks. The pain is described as mild at baseline (2/10) but intensifies to moderate severity (6/10) when wiping after urination. She denies associated urinary symptoms such as dysuria, urgency, or hematuria. There is no report of abnormal vaginal discharge, odor, or systemic symptoms such as fever or malaise. This visit represents her first Pap smear and comprehensive gynecologic evaluation.

Review of Systems

General

The patient denies unexplained weight changes, appetite alterations, fatigue, fever, chills, or night sweats.

Head, Eyes, Ears, Nose, and Throat

She denies visual disturbances, hearing loss, tinnitus, ear pain, dizziness, nasal congestion, epistaxis, sinus discomfort, or changes in smell.

Cardiovascular

She denies chest pain, palpitations, edema, or tachycardia.

Respiratory

She reports no cough, shortness of breath, or dyspnea on exertion.

Gastrointestinal

The patient denies abdominal pain, nausea, vomiting, diarrhea, or constipation.

Genitourinary

She denies urinary frequency, burning, hematuria, or changes in urinary stream. However, she reports vaginal pain, which worsens following urination during wiping.

Musculoskeletal

She denies muscle aches, weakness, or joint pain.

Integumentary

She denies rashes, lesions, pruritus, dryness, or skin discoloration.

Breast

The patient denies breast pain, masses, discharge, or routine performance of self-breast examinations.

Neurological

She denies headaches, seizures, syncope, numbness, or tingling.

Psychiatric

The patient is oriented to person, place, and time and denies mood disturbances or anxiety symptoms.

Endocrine

She denies heat or cold intolerance and reports no changes in hair texture or hair loss.

Hematologic

She denies a history of blood transfusions, easy bruising, or bleeding disorders.

Allergies

The patient reports no known drug, food, or environmental allergies.

Current Medications

The patient reports taking levothyroxine (Synthroid) 75 mcg daily for hypothyroidism.

Immunization History

The patient is uncertain about her adult immunization status and reports her last known vaccinations occurred during childhood.

Past Medical History

The patient has a history of hypothyroidism.

Gynecologic and Obstetric History

Menstrual History

• First day of last menstrual period: January 21

• Cycle length: 26–28 days

• Duration: Approximately five days

• Age at menarche: 12 years

Obstetric History

• Gravida 1, Para 0

• History of one miscarriage

Screening History

• Pap smear: None prior to this visit

• Mammogram: None

Sexual History

The patient reports being sexually active since age 17. She has had a total of two male sexual partners. Her current partner relationship duration is four months, with inconsistent condom use. She reports no current use of contraception.

Surgical History

The patient denies any past surgical procedures.

Family History

The patient reports undergoing genetic testing related to her maternal grandmother’s history of breast cancer.

Social History

The patient consumes approximately one glass of wine per week. She denies tobacco use, vaping, or recreational drug use. She is alert, oriented, and independent in activities of daily living.

Objective Assessment

Vital Signs

Physical Examination

General Appearance

The patient appears well-nourished, well-developed, and in no acute distress.

Skin

Skin is intact with no rashes, lesions, or discoloration.

Head, Eyes, Ears, Nose, and Throat

Head is normocephalic. Sclerae are white without injection. Pupils are equal, round, and reactive to light and accommodation. Tympanic membranes are intact and pearly gray bilaterally. Nasal septum is midline with no discharge. Oral mucosa is moist, and dentition is intact.

Neck

Trachea is midline. Thyroid gland is symmetric, mobile with swallowing, and without enlargement, nodules, or tenderness.

Cardiovascular

Heart rate and rhythm are regular. Normal S1 and S2 are present without murmurs, gallops, or rubs.

Respiratory

Chest expansion is symmetric. Lungs are clear to auscultation bilaterally with no adventitious sounds.

Gastrointestinal

Abdomen is soft, non-tender, and non-distended with active bowel sounds in all quadrants. No organomegaly is noted.

Breast Examination

Breasts are symmetrical and pendulous with no masses, tenderness, skin changes, nipple discharge, or axillary lymphadenopathy.

Genitourinary

Inspection of the external genitalia reveals erythema and irritation. Vesicular lesions are present on the vulva, labia majora, and labia minora. Visual examination of the cervix demonstrates erythema and bilateral vesicular lesions, raising concern for an infectious etiology.

Extremities

No deformities, cyanosis, edema, or varicosities are observed. The patient ambulates without difficulty.

Neurological

The patient is alert and oriented to person, place, and time with a pleasant affect.

Procedure Note: Pap Smear and Pelvic Examination

The patient provided verbal consent for a screening Pap smear and pelvic examination with a female chaperone present. The risks and benefits of the procedure were explained prior to initiation. The patient was positioned in the lithotomy position. External genitalia were inspected and palpated, revealing no masses or tenderness. The urethra was intact without prolapse.

A lubricated plastic speculum was inserted, allowing visualization of the vaginal walls and cervix. Cervical cytology samples were obtained using a cytobrush, and additional vaginal secretions were collected for laboratory analysis and culture. A bimanual examination revealed a midline, smooth, freely mobile, and non-tender uterus with no adnexal masses or tenderness. The bladder was non-distended. The patient tolerated the procedure well.

Post-procedure education included counseling regarding possible mild vaginal spotting and discomfort for one to two days following the examination.

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