Soap Note on Vaginal Yeast Infection

Soap Note on Vaginal Yeast Infection SOAP NOTE ON VAGINAL YEAST INFECTION 2 Soap Note on Vaginal Yeast Infection SUBJECTIVE (S) CC: “I have vaginal itching and irritation, unusual vaginal discharge and a burning sensation when uri nating and during sexual intercourse.” HPI: Ms Y is a 23 years old Caucasian female who visits the office and reports vaginal itching and irritation. She also adds that she has been having a burning sensation during sexual intercourse and during urination and in the past two days, she has been noticing thick white vaginal discharge. Patient states that she started having the vaginal itching and irritation about four days ago and she started having a burning sensation during urination and sexual intercourse about a week ago. Patient states that the symptoms started as mild and have been getting worse as days go by. Patient states that she has a boy friend and that she is sexually active. She denies multiple sexual partners and admits to having unprotected sex. Patient says that she uses Depo-Provera Shot contraceptive. Ms Y states that She has not taken any medication to alleviate the symptoms. She adds that the burning sensation during sexual intercourse has affected her sexual life as well as psychologically. Patient rates the burning sensation and the discomfort of her symptoms as 6/10 and states that the symptoms have made her avoid sexual intercourse in the past few days. Patient also denies douching and states that she has been taking warm showers to try and alleviate symptoms to gain. Patient denies other symptoms like fever, chills, weight loss, fatigue, malaise, and body aches. Patient denies past diagnosis of STIs or vaginal infections. Summary: Patient presents with a chief complaint of vaginal itching and irritation and a burning sensation when urinating and during sexual intercourse. She rates the discomfort of the symptoms as 6/10.