SOAP NOTE
Student Name: Course: NSG6420
Name: Date: 02/01/2024 Time: 1545
Ethnicity: Hispanic Age: 32 Sex: F
SUBJECTIVE
CC: “I have been having white cottage like vaginal discharge and itching”
HPI: A 32-year-old Hispanic female, presents with a chief complaint of white cottage-like
vaginal discharge and itching persisting for the past week. She describes the discharge as a
novel occurrence and notes no associated foul odor. The patient reports a regular menstrual
history, denies recent changes in hygiene or sexual activity, and is in a monogamous
relationship. She has not used any vaginal products or medications and has no history of
sexually transmitted infections or recent antibiotic use. Seeking relief from the discomfort,
she has not attempted self-treatment and hopes for a thorough evaluation to determine the
cause.
Medications: (list with reason for med )
Albuterol Inhaler 90mcg PRN
PMH
Allergies: NSAIDS- Shortness of breath
Medication Intolerances: None
Chronic Illnesses/Major traumas: Asthma
Hospitalizations/Surgeries- N/A
Family History
M: Alive- pre-diabetes
, MGM: Alive- unknown MGF: Alive unknown F: Alive- hypertension PGM: Alive- unknown
PGF deceased- unknown
Social History
Patient reports being in a monogamous relationship with her husband and does not engage in
high-risk sexual behaviors. Ms. Rodriguez resides in a suburban setting and is employed in a
clerical position. She denies usage of drugs, alcohol, or nicotine.
ROS
General Cardiovascular
Patient denies night sweats, fatigue or weakness Denies any chest pain or shortness of breath,
Skin Respiratory
No rash, lesions, or other skin abnormalities Denies dyspnea denies cough.
Eyes Gastrointestinal
Denies any visual changes Denies abdominal pain, nausea, vomiting or
diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Reports white discharge and irritation
Student Name: Course: NSG6420
Name: Date: 02/01/2024 Time: 1545
Ethnicity: Hispanic Age: 32 Sex: F
SUBJECTIVE
CC: “I have been having white cottage like vaginal discharge and itching”
HPI: A 32-year-old Hispanic female, presents with a chief complaint of white cottage-like
vaginal discharge and itching persisting for the past week. She describes the discharge as a
novel occurrence and notes no associated foul odor. The patient reports a regular menstrual
history, denies recent changes in hygiene or sexual activity, and is in a monogamous
relationship. She has not used any vaginal products or medications and has no history of
sexually transmitted infections or recent antibiotic use. Seeking relief from the discomfort,
she has not attempted self-treatment and hopes for a thorough evaluation to determine the
cause.
Medications: (list with reason for med )
Albuterol Inhaler 90mcg PRN
PMH
Allergies: NSAIDS- Shortness of breath
Medication Intolerances: None
Chronic Illnesses/Major traumas: Asthma
Hospitalizations/Surgeries- N/A
Family History
M: Alive- pre-diabetes
, MGM: Alive- unknown MGF: Alive unknown F: Alive- hypertension PGM: Alive- unknown
PGF deceased- unknown
Social History
Patient reports being in a monogamous relationship with her husband and does not engage in
high-risk sexual behaviors. Ms. Rodriguez resides in a suburban setting and is employed in a
clerical position. She denies usage of drugs, alcohol, or nicotine.
ROS
General Cardiovascular
Patient denies night sweats, fatigue or weakness Denies any chest pain or shortness of breath,
Skin Respiratory
No rash, lesions, or other skin abnormalities Denies dyspnea denies cough.
Eyes Gastrointestinal
Denies any visual changes Denies abdominal pain, nausea, vomiting or
diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Reports white discharge and irritation
