I-HUMAN CASE STUDY FOR Sophia Williams is a 34-year-old female
who presents to the OB/GYN clinic with complaints of recurrent
vaginal itching, thick white— WEEK 10 FOR WALDEN UNIVERSITY
LOCATION :OUTPATIENT CLINIC WITH X-RAY, ECG, AND
LABORATORY CAPABILITIES FULL CASE STUDY WITH A SOAP NOTE
Comprehensive OB/GYN Case Study
Recurrent Vulvovaginal Candidiasis
Patient Profile
• Name: Sophia Williams
, • Age: 34 years
• Sex: Female
• Setting: OB/GYN Clinic
• Chief Complaint:
“I keep getting yeast infections.”
History of Present Illness (HPI)
Sophia Williams is a 34-year-old female who presents to the OB/GYN
clinic with complaints of recurrent vaginal itching, thick white
discharge, and vulvar irritation over the past 8 months. She reports 4–5
similar episodes during this period, each diagnosed as a yeast infection
and treated with over-the-counter antifungal creams or single-dose oral
fluconazole, with only temporary relief.
Symptoms typically include:
• Intense vulvar itching
• Thick, white, “cottage cheese–like” vaginal discharge
• Vaginal burning, worse during intercourse
• Mild dysuria without urinary frequency or urgency
She denies:
• Foul-smelling discharge
• Vaginal bleeding
• Pelvic pain
• Fever or chills
She notes symptoms often recur after antibiotic use or prior to
menstruation.
, Past Medical History
• No chronic medical conditions
• No history of diabetes mellitus (never screened recently)
Past Surgical History
• None
Medications
• Oral contraceptive pills (combined estrogen/progestin)
• Occasional OTC antifungal vaginal creams
Allergies
• No known drug allergies (NKDA)
Gynecologic History
• Menarche: Age 12
• LMP: 2 weeks ago
• Cycle: Regular, 28-day cycles
• Gravida/Para: G1P1
• Sexually active: Yes, with one male partner
• Contraception: Oral contraceptive pills
• Pap smear: Up to date; last normal (1 year ago)
• STI history: Denies
who presents to the OB/GYN clinic with complaints of recurrent
vaginal itching, thick white— WEEK 10 FOR WALDEN UNIVERSITY
LOCATION :OUTPATIENT CLINIC WITH X-RAY, ECG, AND
LABORATORY CAPABILITIES FULL CASE STUDY WITH A SOAP NOTE
Comprehensive OB/GYN Case Study
Recurrent Vulvovaginal Candidiasis
Patient Profile
• Name: Sophia Williams
, • Age: 34 years
• Sex: Female
• Setting: OB/GYN Clinic
• Chief Complaint:
“I keep getting yeast infections.”
History of Present Illness (HPI)
Sophia Williams is a 34-year-old female who presents to the OB/GYN
clinic with complaints of recurrent vaginal itching, thick white
discharge, and vulvar irritation over the past 8 months. She reports 4–5
similar episodes during this period, each diagnosed as a yeast infection
and treated with over-the-counter antifungal creams or single-dose oral
fluconazole, with only temporary relief.
Symptoms typically include:
• Intense vulvar itching
• Thick, white, “cottage cheese–like” vaginal discharge
• Vaginal burning, worse during intercourse
• Mild dysuria without urinary frequency or urgency
She denies:
• Foul-smelling discharge
• Vaginal bleeding
• Pelvic pain
• Fever or chills
She notes symptoms often recur after antibiotic use or prior to
menstruation.
, Past Medical History
• No chronic medical conditions
• No history of diabetes mellitus (never screened recently)
Past Surgical History
• None
Medications
• Oral contraceptive pills (combined estrogen/progestin)
• Occasional OTC antifungal vaginal creams
Allergies
• No known drug allergies (NKDA)
Gynecologic History
• Menarche: Age 12
• LMP: 2 weeks ago
• Cycle: Regular, 28-day cycles
• Gravida/Para: G1P1
• Sexually active: Yes, with one male partner
• Contraception: Oral contraceptive pills
• Pap smear: Up to date; last normal (1 year ago)
• STI history: Denies
