WGU D 117 FEMALE GENITOURINARY SOAP NOTE FORM UPDATED 2025 WITH COMPLETE SOLUTION

Date: 04/02/2025 Name: Maya S. (22-year-old female) DOB: 01/01/XXXX SUBJECTIVE Chief Complaint: Annual women’s wellness visit History of Present Illness: 22-year-old female presents for an annual gynecological visit. Pt complains of external vaginal pain. Pt states that her pain is a 2 out of 10 and increases in pain when she cleanses herself after using the restroom or during intercourse. Pt has not tried any alleviating interventions. Pt describes the pain as “burning” or “stinging.” Review of Systems: General: Well-nourished, well-developed, alert, and cooperative, and in no apparent distress. Pt denies any unexplained fatigue, fever, chills, or night sweats. Pt does report having low thyroid. HEENT: Pt denies any changes to her vision. Pt states hearing is intact denies ringing in her ears, pain, and drainage. Pt does not complain of vertigo. Pt denies any change in smells, recent epistaxis, or congestion. Pt denies any dental issues, sores in mouth, or frequent sore throats. Cardiac: Pt denies any heart palpitations, chest pain, or edema Pulmonary: Pt denies cough and shortness of breath GI: Pt denies abdominal pain, nausea, vomiting, diarrhea, or constipation GU: Pt denies pain with urination. Pt does complain of pain when cleaning self and during intercourse. Pt rates this pain 6/10. Denies polyuria, oliguria, and hematuria. Pt also denies vaginal discharge. Musculoskeletal: Pt denies any muscle pain, weakness, or joint pain Skin: Pt denies any rashes, hives, lumps, sores, dryness, or itching. Breast: Pt denies any pain, tenderness, lumps, or discharge from her breasts. Pt does not regularly perform self-breast exams, but does so occasionally. Neuro: Pt denies headaches, seizures, and syncopal episodes. Denies any numbness or tingling. Psychiatric: No known psychiatric history. Pt denies anxiety and depression. Pt does state she feels a little down right before the beginning of her cycle. Endocrine: Pt denies heat and cold intolerances. Pt denies hair loss or changes. Hematologic: Pt denies easy bruising or bleeding gums. Pt denies any blood transfusions. Allergies: Pt states she has no known allergies. Medications: Pt states that she takes 75mcg of thyroid medication called levothyroxine. Immunizations: Pt is a poor historian regarding immunizations. Pt states she had “some” when she was a child, and does not remember receiving any vaccines as a teenager. Pt does not recall if she received HPV vaccine. Past Medical History: Hypothyroidism GIM2: Female Reproductive System Female Genitourinary SOAP Form Gynecologic History: Pt denies any previous gynecologic exams. Pt is sexually active with her current boyfriend that she has been with for four months. Menstrual History: FDLMP:January 21st Menarche: 12 years of age OB History: Pt does report one miscarriage. Last Pap Smear: Pt does not report any previous pap smears Last Mammogram: Pt does not report having a mammogram. PAGE 1 GIM2: Female Reproductive SystemFemale Genitourinary SOAP Form Sexual History: Pt states she is sexually active and is inconsistent with condom protection. Occasionally uses “pulling out” method. Pt has been with sexual partner for the last four months and has had one prior sexual partner. General History: Hypothyroidism Surgical History: No past surgical history Family History: Pt states maternal grandmother has a history of breast cancer and is done with treatment. Paternal grandmother has a history of hypertension. Genetic Testing History: Pt does report being tested for genes related to breast cancer. Pt does report having BRCA1 gene. Social History: Pt states she drinks about one glass of wine per week. Denies smoking and drug usage.