Exam (elaborations)
FEMALE GENITOURINARY SOAP NOTE FORM UPDATED 2024 WITH COMPLETE SOLUTION
- Course
- WGU D117
- Institution
- Western Governors University
FEMALE GENITOURINARY SOAP NOTE FORM UPDATED 2024 WITH COMPLETE SOLUTION
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By: llperry4664 • 1 month ago
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2024Female Genitourinary SOAP Note Form 2024
with complete solution
WISEMAN
, GIM1: Female Reproductive System
Female Genitourinary SOAP
Note Form
Name: Maya S.
DOB:
01/01/XXXX
SUBJECTIVE:
Chief Complaint: Annual women’s visit
History of Present Illness: 22-year-old female presents for first pap smear and
gynecological exam. Reports vaginal pain 2/10, increasing to 6/10 when she
wipes. Describes pain as burning or stinging with an onset of two weeks ago.
Review of Systems:
General: Denies recent changes in weight or appetite. Denies fever, chills, night
sweats, and fatigue.
HEENT: Denies vision changes. Denies ringing in ears, difficulty hearing, drainage,
and pain. Denies stuffiness, nasal drainage, nose bleeds, sinus pain, and reduced
sense of smell.
Denies bleeding gums, sore throat, hoarseness, sores in the mouth, problems
with teeth, and any changes to voice.
Cardiac: Denies chest pain, palpitations, tachycardia, edema, and arrhythmias.
Pulmonary: Denies cough, shortness of breath, and difficulty breathing.
GI: Denies abdominal pain, nausea, vomiting, diarrhea, and constipation.
GU: Denies dysuria, hematuria, urinary frequency, discharge, and pain during
intercourse. Reports vaginal pain 2/10, increases to 6/10 when wiping.
Musculoskeletal: Denies muscle pain, weakness, and joint
pain. Skin: Denies rashes, hives, lumps, dryness, sores, and
itching. Breast: Denies pain, tenderness, lumps, and
discharge.
, GIM1: Female Reproductive SystemFemale Genitourinary SOAP Form
Neuro: Denies dizziness, headache, fainting, numbness, tingling, and seizures.
Psychiatric: Not discussed with the patient at this visit.
Endocrine: Denies intolerance to heat and cold. Denies hair
loss. Hematologic: Denies bruising easily. Denies bleeding
gums.
Allergies: No known allergies
Medications: Patient states “75 of the thyroid medication”. Needs verification.
Immunizations: Unknown, patient is a poor historian; last vaccines during
childhood. Past Medical History: Hypothyroidism
Gynecologic History:
Menstrual History: FDLMP: 1/21 Menarche: Onset age 12, reports regular every 26-
28 days lasting five days.
OB History: G1P0, reports
miscarriage. Last Pap Smear: None
Last Mammogram: None
Sexual History: Sexually active with male partners from the age of 17. Patient has
had two male partners. Current partner for four months. Denies use of birth control
with inconsistent use of condoms.
General History: Denies any other
complaints. Surgical History: None
Family History: Maternal grandmother had breast cancer with chemotherapy treatment.
Paternal grandmother has hypertension.
Genetic Testing History: Testing related to breast cancer due to Grandmother’s
history reports having “one of the genes related to breast cancer.”
Social History: Denies smoking and use of recreational drugs. Drinks 1 glass of wine per
week.
OBJECTIVE:
Physical Exam:
Vitals: BP: 108/68 mm/Hg, HR: 78 bpm, RR: 16 bpm, T: 98.7°F, Ht: 5'2", Wt: 54.9 kg (121
lbs.), BMI:
22.1 kg/m2
General: Well-nourished, well-developed individual, NAD
Skin: No rashes or lesions
HEENT: Normocephalic, white sclera, no conjunctival injection, PERRLA, pearly gray
TM B/L, no nasal discharge, nasal septum midline, throat without lesions or
exudates, MMM, clean dentition
Neck: Trachea midline; thyroid midline, equally rises and falls; no enlargement,
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