Female Reproductive System:

D117 GIM2:

Female Reproductive System:

Female Genitourinary

SOAP NOTE FORM 1 / 2

GIM2: Female Reproductive SystemFemale Genitourinary SOAP Form

Date: 6/4/25

Female Genitourinary SOAP Note Form

Name: Maya S. (22-year-old female)

DOB: 01/01/XXXX

SUBJECTIVE

Chief Complaint: Annual well-woman’s visit

History of Present Illness (OLDCARTS):

Patient is a 22-year-old-female that presents to the clinic for her first well woman’s visit. Patient complains of external vaginal pain that started a couple weeks ago. She describes the pain as burning and stinging to her vulvar area with no radiation. Reports The pain is constantly a 2/10 but a 6/10 with aggravating factors, sexual intercourse or when she wipes after urination. No alleviating factors reported.

Review of Systems:

General: Denies weight or appetite changes, fatigue, fever, chills or night sweats.

HEENT: Denies visual or hearing issues, ear pain or drainage, vertigo, headache, difficulty swallowing, epistaxis, nasal congestion, sinus problems or drainage, oral or dental issues.

Cardiac: Denies chest pain, dyspnea, palpitations

Pulmonary: Denies cough, dyspnea, or recent respiratory infections

GI: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation

GU: Positive for vulvar pain with sexual intercourse and wiping after urination. Denies vaginal discharge or hematuria.

Musculoskeletal: Denies muscle weakness, joint pain

Skin: Denies rashes, lesions, hives, lumps, dryness, or itching

Breast: Denies lumps or changes to breast, does not complete sel-exams every month.

Grandmother had breast cancer, and she is positive for BRCA1 gene

Neuro: Denies headaches, seizures, syncope, numbness or tingling

Psychiatric: Denies

mood changes but feels a little “down” before her period

Endocrine: Hypothyroid on

Levothyroxine 75 mcg daily

Hematologic: Denies blood transfusions, or bleeding easily

Allergies: NKA

Medications: Levothyroxine 75 mg Q am

Immunizations: Unknown immunization status, received childhood vaccines, and does not recall HPV vaccine

Past Medical History: Hypothyroidism Surgical

History: No reported surgical history

Gynecologic

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