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Tina is a 27-year-old female who presents to the clinic complaining of a painful burning sensation in her left labial area for 3 days.  She reports recently having unprotected vaginal intercourse with a new male partner. Upon examination, you note fluid-filled vesicles on the left labia minora that are painful to touch. 

Problem-Focused SOAP Note Format

Demographic data

27 year old, female

Subjective

Subjective

Chief Complaint (CC): Burning sensation on L labial area, fluid-filled vesicles, STD

History of Present Illness (HPI): 27 yr old female presents to clinic complaining of a painful burning sensation in her left labial area for 3 days. She reports recently having unprotected vaginal intercourse with a new male partner. Endorses that she has blisters on the left side of her vaginal that are painful to touch.

Past Med. Hx (PMH): No significant PMH. Denies hospitalization, surgical problems, allergies to food or drugs. No past history of STD. Nulligravida

Social Hx: Reports socially drinking 1-2 times a week. Denies smoking. She lives alone in an apartment. Currently finishing her masters degree in political science with aspirations to be a lawyer. She is currently sexually active and does not practice safe sex.

Review of Systems (ROS)

General: (-) pain, chest pain, fever, weight loss/gain, night sweats, chills, and changes in sleep. (+) fatigue. Are you having any fatigue? Are you currently in pain? Are you experiencing more stress than usual? Have you ever had any STI or any reproductive health issues?

HEENT: (-) sore throat, cold sores, difficulty swallowing, headache, dizziness, vision changes, hearing changes, nasal congestion, sinus pain or rhinorrhea, neck tenderness

Lungs: (-) SOB, pain, cough or wheezing, sputum production, prior tuberculosis, pleurisy, coughing up blood

Heart: (-) chest pain, dyspnea, edema, palpitations or syncope.

GU: (+) burning with urination, (-) frequency, urgency, or dribbling with urination. Reports urine is yellow, no hematuria.

Dermatologic: (-) single large ulcers (+) multiple small blisters on L side of Vagina, itchiness, pain to touch, rash of blisters

Genitalia: (+) pain, (-) odor, or drainage, first day of her last menstrual period and the pattern of menses: Novemver, 1th, 2024, Regular, 3-4 pads a day for 3 days Has never done a pap smear before. She is sexually active and does not practice safe sex.

Up to date on all Immunization: had HPV 2 doses already

Objective

VS: BP: 118/76, HR 70, RR:16, TEMP 98.4, O2 SAT: 100% HT: 61.2 inches WT: 129lbs

Negative Pregnancy Test

General: 27 y/o female, AAOx4, interactive and answers appropriately. Well developed, and nourished.

HEENT: No oral lesions present, NC/AT, PERRL, EOMI, good conjugate gaze, Nares patent bilaterally, no sinus pain or pressure, MMM, oropharynx without erythema, no exudate from throat, Tonsils 1+. neck is Supple, Normal ROM, no lymph node swelling, no masses noted.

Lungs: Normal respiratory effort, even and unlabored, CTAB, no cough, wheezing or rhonchi present

Heart: RRR, normal s1/s2, no m/r/g, no edema

Dermatologic: Skin is warm, dry and intact. Nailbeds pink with no cyanosis or clubbing, poor skin turgor. Erythema present with multiple small fluid filled vesicles present on L labia, no anal sores present.

Genitalia: L labia multiple fluid filled vesicles present, no other abnormal finding found with pelvic exam

Pelvic:

o External genitalia: triangle eschucheon, multiple fluid filled vesicles present, some lesions are crusted on L labia

o Vagina: Rugated, no discharge, no odor, pH4.5.

o Cervix: 3 x 3 cm, no motion tenderness, patent os without discharge, no lesions.

o Uterus: Small, mobile, midline, anteverted, non-tender.

o Adnexae: No obvious masses or tenderness bilaterally

Differential dx:

Z11. 51 Encounter for screening for human papillomavirus (HPV)

Pertinent positive: pruritus (Hollier, 2021)

Pertinent negative: soft, painless, flesh-colored warts (Hollier, 2021)

A53 Other and unspecified syphilis

Pertinent positive: unprotected sex with new partner, sores in vaginal area, fatigue (Hollier, 2021)

Pertinent negative: chancroid, flu-like symptoms (Hollier, 2021)

N77.1 Vaginitis, vulvitis and vulvovaginitis in diseases classified elsewhere

Pertinent positive: itchiness, erythema (Hollier, 2021)

Pertinent negative: vaginal discharge, odor (Hollier, 2021)

Final Diagnosis:

A60.04 Herpesviral vulvovaginitis

Pertinent positive: unprotected sex with new partner, itchiness, erythema, fluid filled vesicles, painful ulcerations, dysuria, malaise (Hollier, 2021)

Plan:

Labs: Pregnancy test – Negative, STD panel- Positive for HSV 2, CT/NG-Neg, HIV-Neg (recently acquired HSV increases the risk of acquiring HIV via contact with infected person (Hollier, 2021), HSV PCR- Positive, Pap smear-no abnormal findings

Medications: Acyclovir 400mg PO TID for 7-10 days, NSAIDs or acetaminophen for pain  (Hollier, 2021)

Education: Prevention strategies discussed, emphasize on consistent use of condoms. Use of condoms during all sexual exposures to decrease risk of transmission when asymptomatic During asymptomatic shedding, genital infections can be transmitted. (Hollier, 2021).

Referral/Follow-up: Re-evaluate in 1 week if no clinical improvement

Health maintenance: Physical exam recommended annually, as well as eye exam. Practice safe sex, Pap smear today and every three years.

References:

Alexander, I. M. (2017). Women's Health Care in Advanced Practice Nursing (2nd ed.). Springer Publishing LLC.  https://online.vitalsource.com/books/9780826190048 Links to an external site.

CDC. (2024, October 8).  Clinical Care of Hepatitis B. Hepatitis B.  https://www.cdc.gov/hepatitis-b/hcp/clinical-care/index.html Links to an external site.

‌Forbes, H., Warne, B., Lars Doelken, Brenner, N., Waterboer, T., Luben, R., Wareham, N. J., Warren-Gash, C., & Effrossyni Gkrania-Klotsas. (2019). Risk factors for herpes simplex virus type-1 infection and reactivation: Cross-sectional studies among EPIC-Norfolk participants. PLoS ONE, 14(5), e0215553–e0215553. https://doi.org/10.1371/journal.pone.0215553

GROVES, M. J. (2016). Genital Herpes: A Review. American Family Physician, 93(11), 928–934.  https://www.aafp.org/pubs/afp/issues/2016/0601/p928.html Links to an external site.

Herpes - STI Treatment Guidelines. (2022, September 21). Cdc.gov.  https://www.cdc.gov/std/treatment-guidelines/herpes.htm Links to an external site.

Hollier, A. (2021). Clinical guidelines in primary care. (4th ed.). Lafayette, LA: Advanced Practice Education Associates

Jordan, R. G., Farley, C. L., & Grace, K. T. (2018). Prenatal and Postnatal Care: A Woman Centered Approach (2nd ed.). Wiley Global Research (STMS). https://online.vitalsource.com/books/9781119318361

Syphilis - STI Treatment Guidelines. (2024, October 3). Cdc.gov. https://www.cdc.gov/std/treatment-guidelines/syphilis.htm

‌

Katherine

Demographics

 

▪ Age: 27-year-old 

▪ Gender: Female

 

Subjective

 

▪  Chief Complaint (CC): 

Painful burning sensation in the left labial area for 3 days.

 

▪  History of Present Illness (HPI): 

Tina is a 27-year-old female presenting with a 3-day history of a painful burning sensation localized to the left labial area. She describes the pain as constant and sharp, worsening with contact, and reports fluid-filled lesions on the left labia minora. Tina recently engaged in unprotected vaginal intercourse with a new male partner approximately one week before the onset of symptoms. She denies any other unusual vaginal discharge, fever, or systemic symptoms.

 

▪  Medications: None reported

 

▪  Allergies: None reported

 

▪  LMP: 10 days ago (normal and regular)

 

▪  Gyn/OB History:

Menarche at age 12

No previous history of sexually transmitted infections (STIs)

No pregnancies, G0P0

 

▪  Past Medical History (PMH): No known chronic illnesses or significant medical history.

 

▪  Chronic Illness/ Major Trauma: None reported

 

▪  Family History: No known history of significant illnesses, including STIs or reproductive health issues, in the immediate family.

 

▪  Social History:

Nutrition: Well-balanced diet

Exercise: Regular, moderate physical activity

Substance Use: Occasional alcohol use; denies tobacco and recreational drug use.

Sexual History: Recently initiated a new sexual relationship with one male partner; reports unprotected intercourse. No prior history of multiple or concurrent sexual partners in recent months.

Occupation: Administrative assistant

 

▪  Review of Systems (ROS):

General: Denies fatigue, fever, chills, or weight changes.

Skin: No rashes or other lesions 

ENT: Denies sore throat or nasal congestion.

Cardiovascular: Denies chest pain, palpitations.

Respiratory: Denies cough or shortness of breath.

Gastrointestinal: Denies abdominal pain, nausea, vomiting, or changes in bowel habits.

Genitourinary: Denies dysuria, frequency, or unusual vaginal discharge.

Gynecological: Denies vaginal bleeding or discharge. 

Musculoskeletal: Denies joint pain or muscle weakness.

Neurological: Denies headaches, dizziness, or numbness.

Psychiatric: Denies anxiety or depression symptoms.

 

▪  Additional Questions:

 

HPI Questions:

1. Have you had any similar symptoms in the past?

2. Have you noticed any itching or tingling in the area before the vesicles appeared?

3. Do you have any other symptoms like fever, swollen lymph nodes, or general body aches?

 

Medical History Questions:

1. Have you ever been tested for STIs?

2. Have you had a pap smear or other recent gynecological exams?

 

Social History Questions:

1. How many sexual partners have you had in the past year?

2. Are you using any form of contraception?

3. Do you plan to have protected intercourse in future encounters with this partner?

 

 

Objective Data

▪  Vital Signs:

o Blood Pressure: WNL

o Heart Rate: WNL

o Respiratory Rate: WNL

o Temperature: WNL

o BMI: 23.5

▪  Physical Examination:

o  General: Alert, well developed, well nourished. No acute distress. 

o  Skin: Clear with no notable lesions on general skin examination.

o  HEENT: Normocephalic, no lymphadenopathy noted.

o  Neck: Supple, no cervical lymphadenopathy.

o  Cardiovascular: Regular rate and rhythm, no murmurs.

o  Respiratory: Clear to auscultation bilaterally.

o  Abdomen: Soft, non-tender, no masses noted.

o  Genitourinary: Presence of multiple fluid-filled vesicles on the left labia minora; vesicles are erythematous and painful to touch.

o  Extremities: No edema or tenderness.

o  Neurological: Alert, oriented, no focal deficits.

▪  Point of Care Testing (POCT):

o  Urine pregnancy test: Negative

 

Assessment/Diagnosis

 

▪  Primary Diagnosis:

 

Genital Herpes Simplex Virus (HSV) infection - ICD-10: A60.04 (Herpes viral infection of the vulva)

 

Pertinent Positives:

o Painful burning sensation in left labial area

o Presence of fluid-filled vesicles on labia minora

o Recent unprotected intercourse with a new partner

 

Pertinent Negatives:

o No fever, swollen lymph nodes, or systemic symptoms reported

o No history of previous similar symptoms

 

▪  Differential Diagnoses:

 

Genital Herpes (HSV) - Most likely based on the presentation of vesicles and a new sexual partner.

 

Contact Dermatitis - Considered but unlikely due to vesicular nature and absence of irritants.

 

Plan

 

▪  Diagnostic Tests:

o  HSV PCR or culture from fluid in vesicles to confirm herpes simplex virus type.

o  Syphilis Serology (RPR) for screening, as a standard STI panel.

 

▪  Lab Tests:

o STI panel, including HIV, chlamydia, gonorrhea, and syphilis.

 

▪  Treatment:

o  Medications:

▪ Acyclovir 400 mg orally three times daily for 7-10 days or 

▪ Valacyclovir 1g twice daily for 7-10 days.

▪ Pain Management: Recommend NSAIDs such as ibuprofen for pain relief as needed.

 

▪  Referrals:

o None required at this time unless symptoms persist or recur frequently, in which case referral to gynecology or infectious disease may be considered.

 

▪  Patient Education:

o Educate on HSV as a lifelong infection that can recur, but antiviral medications can help manage symptoms and reduce transmission risk.

o Discuss safe sexual practices, including consistent condom use, to prevent STI transmission.

o Advise on abstinence from sexual activity until lesions heal to prevent transmission.

 

▪  Health Maintenance:

o Recommend regular STI screenings due to new sexual partner.

o Pap smear and HPV testing if not done within the past 3 years.

 

▪  Follow-up:

o Return to clinic in 1-2 weeks to review test results and response to treatment. 

o Educate on signs of recurrence and advise to return if symptoms worsen.

 

 

Reference: 

 

Albrecht, M.A. (2024, October 28). Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection.  UpToDate. Retrieved from  https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-genital-herpes-simplex-virus-infection?search=Genital%20Herpes%20Simplex%20Virus%20%28HSV%29%20infection%20&source=search_result&selectedTitle=2%7E150&usage_type=default&display_rank=2