SCENARIO SOAP NOTE

Case Scenario 1:Denise, a 19-year-old female presents to the clinic for an annual physical exam.
She is G0P0, and presents with irregular menses only occurring every 3-4months
apart within the past 2 years. She is sexually ac ve and only using condoms
occasionally. She is not on any other birth control methods. She denies any
signi cant medical or surgical health history and denies any other current health
problems. She has never had a Pap smear or any pelvic exam tests before today.
Her pregnancy test is nega ve and her vital signs are all WNL.
Write a brief SOAP note regarding this pa ent. Make sure to include your answers
to these ques ons in your SOAP note.
1. Subjec ve:
a. What other relevant ques ons should you ask regarding the HPI?
b. What other medical history ques ons should you ask?
c. What other social history ques ons should you ask?
2. Objec ve:
a. What point of care tes ng (POCT) would you perform or order for this
pa ent?
b. Pa ent states she has not had a pap smear, is it appropriate to
perform a pap on this pa ent? Why or Why not?
3. Assessment/ Diagnosis:
a. What would be an appropriate diagnosis for her? Why?
b. Any other diagnosis or di eren al diagnosis you would like to add?
4. Plan:
a. What will you prescribe for this pa ent? Why?
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b. What pa ent educa on is important to include for this pa ent?
Soap Note
Demographics Data:
Sex: Female
Race: Caucasian
Age: 24 years
Subjective:
Chief complaint (CC): “For the past week, I have had yellow/green vaginal discharge with an
unpleasant odor.”
History of Present Illness (HPI):
Patient is a 24-year-old female who presented to the clinic complaining of yellow/green
vaginal discharge and unpleasant vaginal odor for the past week.The patient states the symptoms
started one week ago and has been constant ever since. She describes the unpleasant odor as
fishy and the discharge as thin and yellow/greenish in color. She denies any aggravating factors.
Patient states she has not had any treatments for the symptoms and there are no reliving factors.
She states the discharge and smell is consistent throughout the day and although it is not painful,
it causes discomfort.
Past Med. (Hx) (PMH):
`
No past medical history reported
Surgical Hx
Denies past surgical history
Current Medication:
None
Allergies:
NKDA
Family Medical History (Hx):
Mother is alive and healthy with no medical conditions
Father is alive and healthy with no medical conditions
Social History (Hx):
The patient is a full time nursing student and is currently living with her parents. She
states she has a safe and happy home environment. The patient follows a strict workout routine
and exercises 5-6 days a week. Regular diet. Patient denies alcohol, tobacco and substance use.
Patient is sexually active with her current boyfriend of 6 months.
Gyn History:
LMP: 04/03/2024
Menses: every 28 days
Menarche: Age 12
Contraception: None
Pap smear: 08/2022, normal per patient
OB History:
G0
Sexual history:
Gender identity: Female
Sexual orientation: Heterosexual
Preferred pronoun: She
Sexual Activity: Sexually active
Pain during intercourse: Denies pain
Current partners: 1 (boyfriend of 6 months)
Partners in the past 3-5 years: 1
History of STIs : None
History of STI testing: None
ROS:
General: Denies fever, chills, weight loss, and fatigue
Cardiac: Denies chest pain and palpitations
Respiratory: Denies difficulty breathing; denies cough
Skin & Breasts: Denies lesions and rashes on the skin. No masses or lumps reported.
GI: Denies abdominal pain or cramping; denies nausea, vomiting
GU: Denies discomfort during urination
OB: Reports increased thin, yellow/green discharge and fishy vaginal odor. No itchiness or
burning reported. No pain during intercourse
Objective
Vitals: BP 110/68 ; P 88 ; RR 21 ; T 97.4 ; Weight 137 lbs
General: The patient is alert and oriented, displaying no signs of acute distress
Cardiac: Regular rate and rhythm; no murmurs
Lungs: Clear to auscultation bilaterally at bases
Abdomen: Soft, non tender
Skin: No lesions or rashes noted
Genital/Rectal: No swelling, rashes, or lesions noted on the skin, especially on the genitalia.
No suprapubic tenderness was noted.
GU/Pelvic Exam:
External genitalia: No lesions or masses. Redness noted.
Vagina: Discharge in the vaginal canal – yellow/green & thin. Odorous
Cervix: Erythematous
Uterus: Non-tender, no masses
Adnexa: Non-palpable
Assessment/Diagnosis
Differential Diagnosis
Bacterial Vaginosis
Pertinent Positives: Vaginal “fishy” odor, thin vaginal discharge
Pertinent Negatives: Vaginal itching
Chlamydia
Pertinent Positives: Abnormal green discharge with foul smell
Pertinent Negatives: Abdominal pain, discomfort during urination, pain during intercourse
Working Diagnosis:
Trichomoniasis
Trichomoniasis is a very common STD caused by infection with Trichomonas vaginalis.
Women with trich may notice a clear, white, yellowish, or greenish vaginal discharge (i.e., thin
discharge or increased volume) with a fishy smell; (CDC, 2022)
Pertinent Positives: Increased volume of yellow/green vaginal discharge, fishy vaginal odor,
redness of genitalia.
Pertinent Negatives: Discomfort during urination
Plan
Dx Plan (lab, x-ray):
Wet mount
Vaginal swab
UA
STI Screening – Chlamydia, Gonorrhea, Trichomoniasis
Tx Plan (meds):
Metronidazole 500 mg 1 tab PO twice daily for seven days
Pt. Education:
Educate the patient on the need to complete the full course of antibiotics even if symptoms
improve.
Educate the patient on the importance of using latex condoms during intercourse
Educate the patient that her boyfriend must also get treated for trichomoniasis
Educate the patient to avoid sexual activity until one week after treatment began and until
symptoms have resolved for both her and her boyfriend.
Educate the patient on routine STI screening tests.
Referral/Follow-Up:
Follow up in two weeks to evaluate treatment and retest to ensure infection is resolved.
Health Maintenance and Screening:
Pap Smear
Breast Exams (SELF)
STI Screenings
Reference:
CDC. (2022). Std Facts – Trichomoniasis. Centers for Disease Control and Prevention. https://
www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm