SOAP note AHA Week 7

Female Genitalia Case Study

Subjective Data:

Pt- Mary Jones, age 40, African American Female

CC: “I’m itching so much down there and it burns when I urinate”

HPI: Pt c/o experiencing itching of the vulva, not relieved by vagasil or douching with vinegar

and water for 1 week. States itching has increased since last night and now it burns when she

urinates. Pt c/o vague discomfort in the lower abdomen (3 of 10). She states she tried to douche

last night but it only made the itching worse. Pt is married with 2 children. She and her husband

use condoms for birth control. She reports douching weekly with vinegar and water. She cleanses

her external genitalia daily with soap and water. She denies previous vaginal discharge or

infections.

PMH: Diabetes Type II since 2005 treated with Metformin 850 mg Bid po. Last HgbA1c was

8.3% one month ago. Her fasting BS was 188 per AM glucometer this am.

Denies surgeries and relevant family history. Is an unemployed paralegal without health

insurance. Reports drinking a six pack of light beer each week. Smokes ½ pack of light cigarettes

daily and uses marijuana most weekend with friends.

Objective Data:

Vitals: Temp 99.8 0

F (37.7 o C), Apical 88 b/m, Resp 22/min, BP 132/82, Glucometer (non-

fasting) 233

Urine Dipstick- Large amt bacteria, trace blood

Physical Labia Majora and minora is covered with a papular red rash. Thick white, odorless

vaginal drainage is noted. Tenderness to palpation of external genitalia. Speculum exam reveals

erthymous vaginal walls with white drainage. Urine cloudy yellow. Uterus is midline and not

enlarged. Ovaries are non tender.

Instructions

1. Prepare a SOAP note using the guidelines attached to the assignment link.

2. Submit the SOAP note to Blackboard- There is no ShadowHealth exam for the breast.

3. Review the “Recording Information” PowerPoint which contains “tips for weekly write

ups”. You will be graded according to these tips.

4. If information is missing that you feel is important, you may add to the case study facts as

needed.

5. Your diagnosis and plan must be comprehensive and include the reference I provided.