NR602 WEEK 7 I HUMAN CASE
FINAL DIAGNOSIS INFECTIOUS
VULVOVAGINITIS CHAMBERLAIN
UNIVERSITY
,SOAP NOTE: Infectious Vulvovaginitis
Patient Name:
Age: [Reproductive age - likely 18-45 based on typical presentation]
Gender: Female
Encounter Date: [Current Date]
Setting: Primary Care Clinic / Women's Health Clinic / Urgent Care
Chief Complaint: "I'm having itching and burning down there, and there's a weird
discharge with a strong odor."
SUBJECTIVE (S)
History of Present Illness (HPI):
The patient is a [age]-year-old female who presents with a chief complaint of vaginal
itching, burning, and abnormal discharge that began approximately [3-5] days ago. She
reports the itching is intense and worse at night, causing significant discomfort and
sleep disturbance. She describes the discharge as [white/gray/yellow/green],
[thick/cottage cheese-like/watery/frothy] in consistency, with a
[yeast-like/fishy/offensive] odor. She endorses external burning, especially with
urination. She denies any fever, chills, or abdominal pain. She reports that her partner
has not complained of any symptoms.
She denies any recent antibiotic use but reports she just finished her menstrual period
[3] days ago. She reports using over-the-counter [Monistat/Vagisil] with minimal relief.
She denies any douching or use of feminine hygiene sprays.
Review of Systems (ROS):
● General: Denies fever, chills, fatigue.
● Genitourinary: Vaginal itching (pruritus), vaginal burning (dyspareunia), abnormal
discharge, odor. Denies dysuria, urinary frequency, hematuria. Denies pelvic pain.
● Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation.
● Musculoskeletal: Denies back pain.
● Skin: Denies rash elsewhere on body.
● Neurological: Denies headaches, dizziness.
, Past Medical History (PMH):
● History of recurrent yeast infections (if applicable)
● No chronic medical conditions
Past Surgical History (PSH):
● None
Medications:
● Over-the-counter Monistat 1 (started yesterday) - no improvement
● No prescription medications
● No antibiotics in past 3 months
Allergies:
● No Known Drug Allergies (NKDA)
Menstrual History:
● LMP: [Date] - regular, 28-day cycle, lasted 5 days, ended 3 days ago
● Gravida/Para: G_P_ (if applicable)
● Contraception: [Oral contraceptives / Condoms / None / IUD]
● Sexual History: Sexually active with [male/female] partner(s). Reports [condoms
/ no condoms] for STI prevention. No new partners in past 3 months. No history
of STIs.
Social History:
● Works as [occupation].
● Denies tobacco use. Reports occasional alcohol use. Denies illicit drug use.
● Lives with partner.
Family History:
● Non-contributory.
OBJECTIVE (O)
FINAL DIAGNOSIS INFECTIOUS
VULVOVAGINITIS CHAMBERLAIN
UNIVERSITY
,SOAP NOTE: Infectious Vulvovaginitis
Patient Name:
Age: [Reproductive age - likely 18-45 based on typical presentation]
Gender: Female
Encounter Date: [Current Date]
Setting: Primary Care Clinic / Women's Health Clinic / Urgent Care
Chief Complaint: "I'm having itching and burning down there, and there's a weird
discharge with a strong odor."
SUBJECTIVE (S)
History of Present Illness (HPI):
The patient is a [age]-year-old female who presents with a chief complaint of vaginal
itching, burning, and abnormal discharge that began approximately [3-5] days ago. She
reports the itching is intense and worse at night, causing significant discomfort and
sleep disturbance. She describes the discharge as [white/gray/yellow/green],
[thick/cottage cheese-like/watery/frothy] in consistency, with a
[yeast-like/fishy/offensive] odor. She endorses external burning, especially with
urination. She denies any fever, chills, or abdominal pain. She reports that her partner
has not complained of any symptoms.
She denies any recent antibiotic use but reports she just finished her menstrual period
[3] days ago. She reports using over-the-counter [Monistat/Vagisil] with minimal relief.
She denies any douching or use of feminine hygiene sprays.
Review of Systems (ROS):
● General: Denies fever, chills, fatigue.
● Genitourinary: Vaginal itching (pruritus), vaginal burning (dyspareunia), abnormal
discharge, odor. Denies dysuria, urinary frequency, hematuria. Denies pelvic pain.
● Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation.
● Musculoskeletal: Denies back pain.
● Skin: Denies rash elsewhere on body.
● Neurological: Denies headaches, dizziness.
, Past Medical History (PMH):
● History of recurrent yeast infections (if applicable)
● No chronic medical conditions
Past Surgical History (PSH):
● None
Medications:
● Over-the-counter Monistat 1 (started yesterday) - no improvement
● No prescription medications
● No antibiotics in past 3 months
Allergies:
● No Known Drug Allergies (NKDA)
Menstrual History:
● LMP: [Date] - regular, 28-day cycle, lasted 5 days, ended 3 days ago
● Gravida/Para: G_P_ (if applicable)
● Contraception: [Oral contraceptives / Condoms / None / IUD]
● Sexual History: Sexually active with [male/female] partner(s). Reports [condoms
/ no condoms] for STI prevention. No new partners in past 3 months. No history
of STIs.
Social History:
● Works as [occupation].
● Denies tobacco use. Reports occasional alcohol use. Denies illicit drug use.
● Lives with partner.
Family History:
● Non-contributory.
OBJECTIVE (O)
