NR602 Week 7 I Human Case Final Diagnosis Infectious Vulvovaginitis Case Study Analysis Patient Presentation Chief Complaint (CC) Vaginal itching, Burning, Abnormal Discharge, or Odor

NR602 Week 7 I Human Case Final
Diagnosis Infectious Vulvovaginitis Case
Study Analysis Patient Presentation Chief
Complaint (CC) Vaginal itching, Burning,
Abnormal Discharge, or Odor 2025-2026
Universal SOAP Note Template


Student’s Name: Date: 05/30/2024


Age: 32
Date of Birth: 01/14/1992
Gender: Male Female Ethnicity: Caucasian
Comment: Patient identifies as female



SUBJECTIVE DATA
Chief "I am having a lot of itching and thick vaginal discharge."
Complaint
(CC)

History of The patient reported significant vaginal itching and a thick white discharge
Present
for the past one week. The patient discovered the vaginal discharge to be
Illness (HPI)
**GYN odorous. Furthermore, she reported the itching to be persistent throughout the
Focus**
day but intensifies at night, disrupting her sleep. She does not have a fever,

pelvic pain or burning sensation during urination. The patient states that she

has been suffering from the symptoms and has found minimal relief with

over-the-counter antifungal creams. She complains that these symptoms are




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,NR602 Week 7 I Human Case Final
Diagnosis Infectious Vulvovaginitis Case
Study Analysis Patient Presentation Chief
Complaint (CC) Vaginal itching, Burning,
Abnormal Discharge, or Odor 2025-2026
affecting her daily personal life. She describes her level of distress as

moderate to severe.


OB/GYN The patient is Gravida 2, Para 2. Her last menstrual period started two weeks
history
ago and was normal in duration and flow. Her last PAP smear, conducted

annually, was performed one year ago with normal results. The patient reports

using oral contraceptives as her primary method of birth control for the past

five years, with no recent changes.


Sexual The patient reported having a monogamous relationship with her husband of
History
eight years. She also states that she does not have any history of sexually

transmitted diseases, and she reports that she has not had any new sexual

partners. She says that her sexual activity has decreased recently due to the

discomfort caused by her symptoms.


Past Medical  Uncomplicated pregnancies and deliveries .
History
(PMH)  Appendectomy (2010)

 The patient denies any history of chronic diseases, allergies or
ongoing medication other than oral contraceptives.



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, NR602 Week 7 I Human Case Final
Diagnosis Infectious Vulvovaginitis Case
Study Analysis Patient Presentation Chief
Complaint (CC) Vaginal itching, Burning,
Abnormal Discharge, or Odor 2025-2026
Past Surgical  Appendectomy (2010)
History
(PSH)  No postoperative complications.

Immunizatio The patient is up-to-date on all her vaccinations, including the annual
n status
influenza vaccine and the tetanus booster given ten years ago.

The patient denies any history of significant adverse reactions or allergies to

any vaccines.

Medications The patient is not currently taking any prescription medications.
**birth
The patient currently takes oral contraceptive pills:
control**
1. Ethinyl estradiol taken once daily

2. levonorgestrel taken once daily

Allergies The patient reports having no known allergies to drugs, food or environment.

Family The patient's mother has a history of type 2 diabetes and hypertension. Her
History (FH)
father is healthy with no significant medical history. She has one sibling, a

sister, who has been diagnosed with hypothyroidism.

Social Marital status: She is married with two children.
History (SH)
Lifestyle risk factors:




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