WOMEN’S HEALTH MINI SOAP
NOTES
Course
WOMEN’S HEALTH MINI SOAP NOTES
SOAP Note #1 – Urinary Tract Infection (UTI)
S – Subjective
24-year-old female reports burning with urination for 3 days.
Increased urinary frequency and urgency.
Denies fever, flank pain, or vaginal discharge.
O – Objective
Temperature: 98.6°F
BP: 118/72 mmHg
Urinalysis positive for leukocytes and nitrites.
A – Assessment
Acute uncomplicated urinary tract infection.
P – Plan
Prescribe Nitrofurantoin 100 mg PO BID for 5 days.
Encourage increased fluid intake.
Educate on proper perineal hygiene.
Follow up if symptoms worsen or persist.
SOAP Note #2 – Vaginal Candidiasis
S – Subjective
29-year-old female complains of vaginal itching and thick white discharge for 1 week.
Denies fever or pelvic pain.
O – Objective
Vulvar erythema present.
Thick, white, cottage cheese-like discharge noted.
,A – Assessment
Vulvovaginal candidiasis.
P – Plan
Fluconazole 150 mg PO single dose.
Avoid scented hygiene products.
Return if symptoms persist beyond 7 days.
SOAP Note #3 – Bacterial Vaginosis
S – Subjective
32-year-old female reports fishy vaginal odor and thin gray discharge for 5 days.
No pelvic pain.
O – Objective
Vaginal pH >4.5.
Thin gray discharge observed.
A – Assessment
Bacterial vaginosis.
P – Plan
Metronidazole 500 mg PO BID for 7 days.
Avoid alcohol during treatment.
Patient education regarding recurrence prevention.
SOAP Note #4 – Dysmenorrhea
S – Subjective
18-year-old female complains of severe menstrual cramps during first 2 days of menses.
Pain rated 7/10.
O – Objective
Vital signs stable.
, Abdomen soft, mild lower pelvic tenderness.
A – Assessment
Primary dysmenorrhea.
P – Plan
Ibuprofen 600 mg every 6 hours as needed.
Heating pad recommended.
Discuss hormonal contraceptive options if symptoms continue.
SOAP Note #5 – Prenatal Initial Visit
S – Subjective
27-year-old female presents after positive home pregnancy test.
LMP 8 weeks ago.
Mild nausea and fatigue.
O – Objective
Positive urine pregnancy test.
BP 112/68 mmHg.
A – Assessment
Intrauterine pregnancy approximately 8 weeks gestation.
P – Plan
Begin prenatal vitamins with folic acid.
Order prenatal laboratory tests.
Schedule first-trimester ultrasound.
Provide pregnancy education.
SOAP Note #6 – Contraceptive Counseling
S – Subjective
22-year-old female requests birth control.
NOTES
Course
WOMEN’S HEALTH MINI SOAP NOTES
SOAP Note #1 – Urinary Tract Infection (UTI)
S – Subjective
24-year-old female reports burning with urination for 3 days.
Increased urinary frequency and urgency.
Denies fever, flank pain, or vaginal discharge.
O – Objective
Temperature: 98.6°F
BP: 118/72 mmHg
Urinalysis positive for leukocytes and nitrites.
A – Assessment
Acute uncomplicated urinary tract infection.
P – Plan
Prescribe Nitrofurantoin 100 mg PO BID for 5 days.
Encourage increased fluid intake.
Educate on proper perineal hygiene.
Follow up if symptoms worsen or persist.
SOAP Note #2 – Vaginal Candidiasis
S – Subjective
29-year-old female complains of vaginal itching and thick white discharge for 1 week.
Denies fever or pelvic pain.
O – Objective
Vulvar erythema present.
Thick, white, cottage cheese-like discharge noted.
,A – Assessment
Vulvovaginal candidiasis.
P – Plan
Fluconazole 150 mg PO single dose.
Avoid scented hygiene products.
Return if symptoms persist beyond 7 days.
SOAP Note #3 – Bacterial Vaginosis
S – Subjective
32-year-old female reports fishy vaginal odor and thin gray discharge for 5 days.
No pelvic pain.
O – Objective
Vaginal pH >4.5.
Thin gray discharge observed.
A – Assessment
Bacterial vaginosis.
P – Plan
Metronidazole 500 mg PO BID for 7 days.
Avoid alcohol during treatment.
Patient education regarding recurrence prevention.
SOAP Note #4 – Dysmenorrhea
S – Subjective
18-year-old female complains of severe menstrual cramps during first 2 days of menses.
Pain rated 7/10.
O – Objective
Vital signs stable.
, Abdomen soft, mild lower pelvic tenderness.
A – Assessment
Primary dysmenorrhea.
P – Plan
Ibuprofen 600 mg every 6 hours as needed.
Heating pad recommended.
Discuss hormonal contraceptive options if symptoms continue.
SOAP Note #5 – Prenatal Initial Visit
S – Subjective
27-year-old female presents after positive home pregnancy test.
LMP 8 weeks ago.
Mild nausea and fatigue.
O – Objective
Positive urine pregnancy test.
BP 112/68 mmHg.
A – Assessment
Intrauterine pregnancy approximately 8 weeks gestation.
P – Plan
Begin prenatal vitamins with folic acid.
Order prenatal laboratory tests.
Schedule first-trimester ultrasound.
Provide pregnancy education.
SOAP Note #6 – Contraceptive Counseling
S – Subjective
22-year-old female requests birth control.
