Soap Note Example

Name: XY

Date:

Age: 34 years

Sex: Female

Subjective

CC: “I am experiencing a foul smelling white discharge from my vagina, itchiness and urgency to visit the washrooms.”

A 34-year-old female who presents in the clinic with complains of foul smelling white discharge from her vagina for three weeks which she experiences together with itchiness around her vitals. She also complains about the urgency to visit the washroom like 3x in an hour which has a burning sensation. No distress noted in the patient. The patient denies having a fever, abdominal cramps, nausea, vomiting, vaginal bleeding, and diarrhoea, changes in stool consistency or hematuria. She has never experienced this symptom before and has no history of STDs.

Social history:

Pt is married with two children, a stay at home mother with no history of smoking nor drinking. She reports having just one sex partner and three lifetime partners although reports that her husband has several sex partners. She does not use a condom as she claims to be allergic to latex. The patient states to be a form four leaver with no further education. She claims to be physically active as she has enrolled in a gym and does all house chores. Consumes regular healthy diets with occasional caffeine consumption.

Medications

None

Family history

+ For arthritis in mother aged 61.

+ For DM and HTN in father aged 66.

PMH

Allergies; no drug allergy, allergic to animal protein when taken continuously, allergic to latex, no environmental allergies.

Blood transfusion / operations: None.

Chronic illness: None

Hospitalisation: None

Habits: does not smoke or drink.

Obstetrical hx:

Two pregnancies, both pregnancies delivered alive via vaginal delivery mode with babies at term with no complications.

No hx of abortions nor miscarriages.

LMP three weeks ago, heavy but normal, a flow of 3/7, no complains of bleeding nor spotting since then, no previous PAP smear nor mammogram.

Currently on IUD method of family planning for the past one year four months.

ROS

General: pt. denies any fevers, chills, fatigue and weakness.

HEENT: denies any hearing and vision problems, oral sores, nasal congestions and headaches.

Cardiac: denies of any palpitations or DOB.

GI: denies of diarrhea, constipation, nausea, vomiting, heartburn, difficulty in swallowing.

Neuro: denies of any numbness, weakness, seizures and paresthesia.

Gynecological: as presented above. Denies of vesicular lesions on the labials, change in urine color and any complaints with the previous LMP. Denies any breast lumps, tenderness or breast discharge.

Musculoskeletal: denies of any joint swellings, backaches, stiffness and hx of fracture.

PE.

Weight: 147 lbs.

Height: 5ft 5 inches

BMI: 24.4

Temp: not taken.

BP: 132/84 mmHg

Pulse: 84 beats per min

General appearance:

XY is a young female with no distress, alert and well-nourished.

Skin:

Skin is pink, warm and dry. (PWD)

HEENT:

Head normocephalic, eyes and ears not checked due to time limits, non-enlarged thyroids, no nasal congestions, mucous membranes moist, no thyromegaly nor nodules on the neck. Neck soft and not stiff.

Cardiac and respiratory.

Lungs CTA, lymph nodes non-palpable, chest posteriorly bilateral, no murmurs or clicks heard.

Abdomen:

Non-distended, no hepatomegaly, non-tender and presence of BS.

Extremities:

No edema, warm, cap refill <2min and no skin breaks noted.

Breasts:

Symmetrical, tender, no discharge or swellings.

Genitourinary:

Shaven pubic hair scant, white foul smelling discharge noted, pink vaginal walls, smooth uterus within normal limits, non-palpable ovaries, no hemorrhoids or masses.

Psychiatric:

Alert, clear speech and answers quizzes appropriately.

Lab tests:

Chlamydia culture, swab test, urine culture, HbA1C- awaiting results.

Diagnosis:

Differential diagnoses

Candidiasis

This is an infection which is commonly known as yeast infection where the healthy yeasts in the vagina out grow beyond control. This thus leads to irritation and itchiness around the vagina. This condition can be promoted by some factors including hormonal changes especially during menstruation, pregnancy, compromised immune system, diabetes and side effects to some drugs (Glaser, et.al). This infection is also seen in men but not as common. Sample used is mostly urine.

Herpes simplex

This is a condition caused by a virus that attacks the vaginal cavity. It has two types, type 1 is transmittable through oral secretions and thus can be spread through kissing, sharing toothbrushes, utensils, or coming into contact with a person with skin sores. Type 2 is transmitted through sexual intercourse with an infected person. The common reported symptom is mostly pain and itching when passing urine (Koelle DM, Corey L).

Chlamydia

This is a rampant sexually transmitted disease whose incubation period for symptoms is long such that one would rarely know if they are having it. Some of its symptoms are pain around the pelvic area especially during sex, abnormal discharge from the vagina and sometimes it could cause bleeding in the vagina. If this condition is not treated, it could lead to complications such as bareness, ectopic pregnancy and other pregnancy complications (Bayramova, et.al).

Plan

Medication: fluconazole cream OD for 7 days, flagyl 500mg BD for 5 days.

Non-medical treatment: drinking of plenty of water, 6-8 glasses per day, regular changing of tampons and wiping front to back after using the washroom.

Follow-up: in 1 week if symptoms persist.