i-Human Case Study: Sophia Williams Vaginal Candidiasis | NURS Week 10 Walden University SOAP Note

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2. Chief1 Complaint1
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Sophia1Williams1presents1with1recurrent1vaginal1itching1and1thick1white1vaginal1discharge1f
or1the1past121months.1


3. Complaints1 1



• Persistent1vaginal1itching,1worse1at1night1
• Thick,1white,1curd-like1vaginal1discharge1
• Occasional1mild1lower1abdominal1discomfort1
•1
No1dysuria,1hematuria,1or1fever1reported1
• Symptoms1recurrent1despite1intermittent1over-the-
counter1antifungal1use1




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4. Comprehensive1History1Pa
st1Medical1History:1

• No1chronic1medical1conditions1
• Occasional1urinary1tract1infections1in1the1past1
•1
No1history1of1sexually1transmitted1
Surgical1History:infections11

• Cesarean1section161years1ago1

• No1other1gynecologic1surgeries1Medications:1

• Occasional1OTC1antifungal1cream1

• Prenatal1vitamins1

• No1chronic1prescription1medications1Allergies:1

• No1known1drug1allergies1

• No1known1food1allergies1
Family1and1Social1History:1

• Mother1alive,160,1hypertension;1father1alive,162,1diabetes1
• Married,1monogamous1relationship1
•1
Non-smoker,1minimal1alcohol1use1
•1
Works1as1a1teacher1




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