SOAP NOTE
Student Name: Course: NSG6430
Name: S.S. Date: 03/26/2024 Time: 1300
Ethnicity: Hispanic Age: 33 Sex: F
SUBJECTIVE
CC: “I have been having white cottage like vaginal discharge and itching”
HPI: A 33-year-old Hispanic female, presents with a chief complaint of white cottage-like
vaginal discharge and itching persisting for the past week. She reports experiencing
discomfort during urination and sexual intercourse. Patient states she has previously been
diagnosed with yeast infections and suspects a recurrence. 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.
Medications: (list with reason for med )
NONE
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Denies
Hospitalizations/Surgeries- Denies
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:03:22 GMT -05:00
https://www.coursehero.com/file/235913178/NSG6430-Week-7-SOAP-C-Costadocx/
, Family History
M: 53y Alive- pre-diabetes
MGM: 78y Alive- unknown
MGF: 80y Alive unknown
F: 60y Alive hypertension
PGM: 91y Alive- Colon Cancer
PGF deceased- unknown
Social History
Patient reports being in a monogamous relationship with her husband and does not engage in
high-risk sexual behaviors. Patient 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 Deferred,
Skin Respiratory
No rash, lesions, or other skin abnormalities Deferred.
Eyes Gastrointestinal
Deferred Deferred
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:03:22 GMT -05:00
https://www.coursehero.com/file/235913178/NSG6430-Week-7-SOAP-C-Costadocx/
Student Name: Course: NSG6430
Name: S.S. Date: 03/26/2024 Time: 1300
Ethnicity: Hispanic Age: 33 Sex: F
SUBJECTIVE
CC: “I have been having white cottage like vaginal discharge and itching”
HPI: A 33-year-old Hispanic female, presents with a chief complaint of white cottage-like
vaginal discharge and itching persisting for the past week. She reports experiencing
discomfort during urination and sexual intercourse. Patient states she has previously been
diagnosed with yeast infections and suspects a recurrence. 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.
Medications: (list with reason for med )
NONE
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Denies
Hospitalizations/Surgeries- Denies
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:03:22 GMT -05:00
https://www.coursehero.com/file/235913178/NSG6430-Week-7-SOAP-C-Costadocx/
, Family History
M: 53y Alive- pre-diabetes
MGM: 78y Alive- unknown
MGF: 80y Alive unknown
F: 60y Alive hypertension
PGM: 91y Alive- Colon Cancer
PGF deceased- unknown
Social History
Patient reports being in a monogamous relationship with her husband and does not engage in
high-risk sexual behaviors. Patient 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 Deferred,
Skin Respiratory
No rash, lesions, or other skin abnormalities Deferred.
Eyes Gastrointestinal
Deferred Deferred
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:03:22 GMT -05:00
https://www.coursehero.com/file/235913178/NSG6430-Week-7-SOAP-C-Costadocx/
