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
The patient, identified as Maya S., is a 22-year-old female born on January 1, XXXX. She presents for a routine women’s health evaluation and her first comprehensive gynecologic examination.
Subjective Assessment
Chief Complaint
What brings the patient in today?
The patient presents for an annual well-woman visit, which includes her first gynecologic examination and an initial Pap smear for cervical cancer screening.
History of Present Illness
What symptoms is the patient experiencing, and how long have they been present?
Maya S. is a 22-year-old woman attending her first cervical cancer screening appointment. She reports vaginal discomfort that has been present for approximately two weeks. The discomfort is mild at rest, rated as 2 out of 10, but increases to a moderate intensity of 6 out of 10 when wiping after urination. She denies classic urinary tract symptoms, including dysuria, urgency, frequency, or hematuria. Additionally, she reports no abnormal vaginal discharge, malodor, fever, chills, or generalized malaise. This encounter marks her first Pap smear and comprehensive gynecologic evaluation, indicating no prior cervical screening history.
Review of Systems
General
The patient denies recent weight loss or gain, fatigue, fever, chills, night sweats, or appetite changes, suggesting no systemic illness.
Head, Eyes, Ears, Nose, and Throat
She reports no visual disturbances, hearing changes, tinnitus, vertigo, nasal congestion, epistaxis, sinus pain, or alterations in taste or smell.
Cardiovascular
She denies chest pain, palpitations, peripheral edema, or episodes of rapid heart rate.
Respiratory
She reports no cough, dyspnea, wheezing, or shortness of breath with exertion.
Gastrointestinal
The patient denies nausea, vomiting, abdominal pain, diarrhea, constipation, or changes in bowel habits.
Genitourinary
Are there urinary or vaginal concerns?
The patient denies urinary burning, urgency, frequency, hematuria, or changes in urinary stream. However, she endorses vaginal pain that is most noticeable after urination during wiping, raising concern for localized irritation or infection.
Musculoskeletal
She denies joint pain, muscle weakness, stiffness, or myalgias.
Integumentary
The patient reports no rashes, pruritus, lesions, dryness, or abnormal skin pigmentation.
Breast
She denies breast pain, palpable masses, nipple discharge, or routine performance of self-breast examinations.
Neurological
She denies headaches, dizziness, syncope, seizures, numbness, or tingling.
Psychiatric
The patient is fully oriented and denies symptoms of depression, anxiety, mood instability, or sleep disturbances.
Endocrine
She denies heat or cold intolerance, excessive sweating, hair thinning, or changes in skin texture.
Hematologic
She denies easy bruising, prolonged bleeding, clotting disorders, or a history of blood transfusions.
Allergies
The patient reports no known drug, food, or environmental allergies.
Current Medications
The patient reports daily use of levothyroxine (Synthroid) 75 mcg for the management of hypothyroidism, with no reported side effects.
Immunization History
The patient is uncertain regarding her adult immunization status and believes her last vaccinations were administered during childhood. This indicates a need for immunization review and possible updates, including HPV vaccination if not previously completed.
Past Medical History
The patient has a documented history of hypothyroidism, currently managed with medication.
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 |
Her menstrual cycles are regular, suggesting normal ovulatory function.
Obstetric History
The patient is gravida 1, para 0, with a history of one miscarriage. She has no living children.
Screening History
The patient has never undergone a Pap smear or mammogram prior to this visit, consistent with her age and first gynecologic presentation.
Sexual History
When did sexual activity begin, and what are the patient’s current practices?
The patient reports being sexually active since age 17 and has had two lifetime male sexual partners. She has been in her current relationship for four months and reports inconsistent condom use. She is not currently using any form of contraception, placing her at risk for unintended pregnancy and sexually transmitted infections.
Surgical History
The patient denies any prior surgical procedures.
Family History
| Family Member | Medical Condition |
|---|---|
| Paternal Grandparent | Hypertension |
| Maternal Grandmother | Breast cancer (treated with chemotherapy) |
The patient reports having undergone genetic testing related to her maternal grandmother’s history of breast cancer, suggesting awareness of hereditary cancer risk.
Social History
The patient reports consuming approximately one glass of wine per week. She denies tobacco use, vaping, and recreational drug use. She is independent in all activities of daily living and demonstrates appropriate insight and judgment.
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 | 22.1 kg/m² |
All vital signs are within normal limits, and the patient’s BMI falls within the healthy range.
Physical Examination
General Appearance
The patient appears well-developed, well-nourished, alert, and in no acute distress.
Skin
The skin is warm, intact, and without lesions, rashes, or discoloration.
Head, Eyes, Ears, Nose, and Throat
The head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Sclerae are clear. Tympanic membranes are intact bilaterally. Nasal passages are patent, and oral mucosa is moist with intact dentition.
Neck
The neck is supple with the trachea midline. The thyroid gland is symmetrical, non-enlarged, mobile with swallowing, and without nodules or tenderness.
Cardiovascular
Heart sounds are normal with a regular rate and rhythm. No murmurs, rubs, or gallops are auscultated.
Respiratory
The lungs are clear to auscultation bilaterally with symmetrical chest expansion and no adventitious sounds.
Gastrointestinal
The abdomen is soft, non-tender, and non-distended with active bowel sounds in all quadrants. No hepatosplenomegaly is appreciated.
Breast Examination
Breasts are symmetrical with no palpable masses, skin changes, nipple discharge, or axillary lymphadenopathy.
Genitourinary
Inspection of the external genitalia reveals erythema and irritation. Multiple vesicular lesions are observed on the vulva, labia majora, and labia minora. Visualization of the cervix reveals erythema and bilateral vesicular lesions, findings concerning for an infectious etiology such as herpes simplex virus.
Extremities
The extremities are free of 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, pleasant affect.
Procedure Note: Pap Smear and Pelvic Examination
The patient provided verbal informed consent for a pelvic examination and Pap smear, with a female chaperone present throughout the procedure. The risks, benefits, and purpose of the examination were explained prior to initiation. The patient was positioned in the lithotomy position.
External genital inspection revealed no masses or tenderness aside from visible irritation. A lubricated plastic speculum was inserted, allowing visualization of the vaginal walls and cervix. Cervical cytology samples were obtained using a cytobrush, and vaginal secretions were collected for laboratory testing and culture. A bimanual examination demonstrated a midline, smooth, mobile, and non-tender uterus with no adnexal masses or tenderness. The bladder was non-distended. The patient tolerated the procedure well.
Post-procedure counseling included education regarding potential mild spotting and discomfort lasting one to two days, as well as guidance on when to seek medical attention.
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