D117 GIM2:
Female Reproductive System:
Female Genitourinary
SOAP NOTE FORM
, GIM2: Female Reproductive SystemFemale Genitourinary SOAP Form
Female Genitourinary SOAP Note Form
Date: 6/4/25
Name: Maya S. (22-year-old female)
DOB: 01/01/XXXX
SUBJECTIVE
Chief Complaint: Annual well-woman’s visit
History of Present Illness (OLDCARTS):
Patient is a 22-year-old-female that presents to the clinic for her first well woman’s visit. Patient complains of
external vaginal pain that started a couple weeks ago. She describes the pain as burning and stinging to
her vulvar area with no radiation. Reports The pain is constantly a 2/10 but a 6/10 with aggravating
factors, sexual intercourse or when she wipes after urination. No alleviating factors reported.
Review of Systems:
General: Denies weight or appetite changes, fatigue, fever, chills or night sweats.
HEENT: Denies visual or hearing issues, ear pain or drainage, vertigo, headache, difficulty swallowing,
epistaxis, nasal congestion, sinus problems or drainage, oral or dental issues.
Cardiac: Denies chest pain, dyspnea, palpitations
Pulmonary: Denies cough, dyspnea, or recent respiratory infections
GI: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation
GU: Positive for vulvar pain with sexual intercourse and wiping after urination. Denies vaginal
discharge or hematuria.
Musculoskeletal: Denies muscle weakness, joint pain
Skin: Denies rashes, lesions, hives, lumps, dryness, or itching
Breast: Denies lumps or changes to breast, does not complete sel-exams every month.
Grandmother had breast cancer, and she is positive for BRCA1 gene
Neuro: Denies headaches, seizures, syncope, numbness or tingling Psychiatric: Denies
mood changes but feels a little “down” before her period Endocrine: Hypothyroid on
Levothyroxine 75 mcg daily
Hematologic: Denies blood transfusions, or bleeding easily
Allergies: NKA
Medications: Levothyroxine 75 mg Q am
Immunizations: Unknown immunization status, received childhood vaccines, and does not recall HPV vaccine
Past Medical History: Hypothyroidism Surgical
History: No reported surgical history Gynecologic
Female Reproductive System:
Female Genitourinary
SOAP NOTE FORM
, GIM2: Female Reproductive SystemFemale Genitourinary SOAP Form
Female Genitourinary SOAP Note Form
Date: 6/4/25
Name: Maya S. (22-year-old female)
DOB: 01/01/XXXX
SUBJECTIVE
Chief Complaint: Annual well-woman’s visit
History of Present Illness (OLDCARTS):
Patient is a 22-year-old-female that presents to the clinic for her first well woman’s visit. Patient complains of
external vaginal pain that started a couple weeks ago. She describes the pain as burning and stinging to
her vulvar area with no radiation. Reports The pain is constantly a 2/10 but a 6/10 with aggravating
factors, sexual intercourse or when she wipes after urination. No alleviating factors reported.
Review of Systems:
General: Denies weight or appetite changes, fatigue, fever, chills or night sweats.
HEENT: Denies visual or hearing issues, ear pain or drainage, vertigo, headache, difficulty swallowing,
epistaxis, nasal congestion, sinus problems or drainage, oral or dental issues.
Cardiac: Denies chest pain, dyspnea, palpitations
Pulmonary: Denies cough, dyspnea, or recent respiratory infections
GI: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation
GU: Positive for vulvar pain with sexual intercourse and wiping after urination. Denies vaginal
discharge or hematuria.
Musculoskeletal: Denies muscle weakness, joint pain
Skin: Denies rashes, lesions, hives, lumps, dryness, or itching
Breast: Denies lumps or changes to breast, does not complete sel-exams every month.
Grandmother had breast cancer, and she is positive for BRCA1 gene
Neuro: Denies headaches, seizures, syncope, numbness or tingling Psychiatric: Denies
mood changes but feels a little “down” before her period Endocrine: Hypothyroid on
Levothyroxine 75 mcg daily
Hematologic: Denies blood transfusions, or bleeding easily
Allergies: NKA
Medications: Levothyroxine 75 mg Q am
Immunizations: Unknown immunization status, received childhood vaccines, and does not recall HPV vaccine
Past Medical History: Hypothyroidism Surgical
History: No reported surgical history Gynecologic
