Female Genitourinary SOAP Note
Patient Identification
The patient is Maya S., a 22-year-old female born on January 1, XXXX. She presents today for a routine women’s health evaluation, which includes her first comprehensive gynecologic examination.
Subjective Assessment
Chief Complaint
What brings the patient in today?
Maya comes for her annual well-woman visit. This appointment is her first gynecologic exam and 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 reports mild vaginal discomfort persisting for about two weeks. She rates this discomfort as 2 out of 10 at rest but it intensifies to 6 out of 10 during wiping after urination. She denies symptoms typical of urinary tract infection, such as burning, urgency, frequency, or blood in urine. She also reports no abnormal vaginal discharge, foul odor, fever, chills, or general malaise. This visit marks her first Pap smear and complete gynecologic exam, with no previous cervical screening history.
Review of Systems
| System | Patient Report |
|---|---|
| General | Denies recent weight changes, fatigue, fever, chills, night sweats, or appetite disturbances. No systemic illness signs. |
| HEENT | No vision or hearing issues, tinnitus, vertigo, nasal congestion, nosebleeds, sinus pain, or taste/smell changes reported. |
| Cardiovascular | No chest pain, palpitations, peripheral swelling, or rapid heartbeat episodes. |
| Respiratory | Denies cough, shortness of breath, wheezing, or exertional dyspnea. |
| Gastrointestinal | No nausea, vomiting, abdominal pain, diarrhea, constipation, or altered bowel habits. |
| Genitourinary | Denies urinary burning, urgency, frequency, hematuria, or stream changes. Reports vaginal pain post-urination wiping, indicating possible localized irritation or infection. |
| Musculoskeletal | No joint pain, stiffness, muscle weakness, or myalgias. |
| Integumentary | No rashes, itching, lesions, dryness, or unusual pigmentation. |
| Breast | Denies pain, lumps, nipple discharge, or self-exam history. |
| Neurological | No headaches, dizziness, seizures, numbness, or tingling. |
| Psychiatric | Fully oriented; denies depression, anxiety, mood changes, or sleep problems. |
| Endocrine | Denies intolerance to heat/cold, excessive sweating, hair loss, or skin texture changes. |
| Hematologic | Denies bleeding disorders, easy bruising, or blood transfusion history. |
Allergies and Medications
The patient reports no known allergies to drugs, foods, or environmental factors. She takes levothyroxine (Synthroid) 75 mcg daily for hypothyroidism without side effects.
Immunization History
Maya is uncertain about her adult immunizations and recalls her last vaccines were during childhood. This suggests a need to review and possibly update vaccinations, including the HPV vaccine if not previously administered.
Past Medical History
The patient has hypothyroidism, managed with daily 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 |
Maya’s cycles are regular, indicating normal ovulatory function.
Obstetric History
She is gravida 1, para 0, with one miscarriage and no living children.
Screening History
She has never had a Pap smear or mammogram prior to this visit, consistent with her age and first gynecologic evaluation.
Sexual History
When did sexual activity begin, and what are current practices?
Sexual activity began at age 17. Maya has had two male sexual partners in her lifetime. She has been in her current relationship for four months and uses condoms inconsistently. She is not currently on contraception, which poses risks for unintended pregnancy and sexually transmitted infections (STIs).
Surgical History
No previous surgeries reported.
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, indicating awareness of hereditary cancer risks.
Social History
Maya drinks about one glass of wine per week. She denies tobacco, vaping, and recreational drug use. She is independent in daily activities and shows good insight and judgment.
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 the healthy range.
Physical Examination
General Appearance: Well-developed, well-nourished, alert, no distress.
Skin: Warm, intact, no lesions or discolorations.
HEENT: Normocephalic, atraumatic. Pupils equal and reactive, clear sclerae, intact tympanic membranes, patent nasal passages, moist oral mucosa.
Neck: Supple, trachea midline, thyroid symmetrical, non-tender, no nodules.
Cardiovascular: Normal heart sounds, regular rhythm, no murmurs or gallops.
Respiratory: Clear lungs bilaterally, no abnormal sounds.
Gastrointestinal: Abdomen soft, non-tender, no enlargement of liver/spleen.
Breast: Symmetrical, no masses, no nipple discharge, no axillary lymphadenopathy.
Genitourinary: External genitalia show erythema and irritation; multiple vesicular lesions on vulva, labia majora and minora; cervix also erythematous with bilateral vesicular lesions, raising suspicion of herpes simplex virus infection.
Extremities: No edema or deformities; steady gait.
Neurological: Alert, oriented, normal speech, cooperative.
Procedure Note: Pap Smear and Pelvic Examination
The patient gave verbal informed consent for a pelvic exam and Pap smear, with a female chaperone present. The procedure’s risks, benefits, and purpose were explained. Maya was positioned lithotomy.
External genital inspection showed no masses or tenderness apart from irritation. A lubricated plastic speculum was inserted for visualization of the vaginal walls and cervix. Cervical cytology samples were collected via cytobrush, and vaginal secretions were taken for lab testing and culture. The bimanual exam revealed a midline, smooth, mobile, and non-tender uterus with no adnexal masses or tenderness; the bladder was non-distended. Maya tolerated the exam well.
Post-procedure counseling addressed possible mild spotting or discomfort for 1-2 days and when to seek medical care.
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.
U.S. Preventive Services Task Force. (2018). Cervical cancer: Screening. https://www.uspreventiveservicestaskforce.org