A 30-year-old African American female presents with vaginal itching and lower abdominal pain, having experienced symptoms for three weeks. She has attempted over-the-counter treatments without success and expresses concern over potential infections or STDs. The diagnosis includes urinary tract infection and candidiasis, with a treatment plan involving medications and education on symptoms and prevention.

1. SOAP NOTE SAMPLE FORMAT FOR MRC
Name:
LP
Date:
Time:
1315
Age:
30
Sex:
F
SUBJECTIVE
CC:

2. “I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently
moved to Miami. She seeks treatment today after unsuccessful
self-treatment of vaginal itching, burning upon urination, and
lower abdominal pain. She is concerned for the presence of a
vaginal or bladder infection, or an STD. Pt denies fever. She
reports the itching and burning with urination has been present
for 3 weeks, and the abdominal pain has been intermittent
since months ago. Pt has tried OTC products for the itching,
including Monistat and Vagisil. She denies any other urinary
symptoms, including urgency or frequency. She describes the
abdominal pain as either sharp or dull. The pain level goes as
high as 8 out of 10 at times. 200mg of PO Advil PRN reduces
the pain to a 7/10. Pt denies any aggravating factors for the
pain. Pt reports that she did start her menstrual cycle this
morning, but denies any other discharge other that light
bleeding beginning today. Pt denies douching or the use of any
vaginal irritants. She reports that she is in a stable sexual
relationship, and denies any new sexual partners in the last 90
days. She denies any recent or historic known exposure to
STDs. She reports the use of condoms with every coital
experience, as well as this being her only form of
contraceptive. She reports normal monthly menstrual cycles that
last 3-4 days. She reports dysmenorrhea, which she also takes
Advil for. She reports her last PAP smear was in 7/2016, was
normal, and reports never having an abnormal PAP smear
result. Pt denies any hx of pregnancies. Other medical hx
includes GERD. She reports that she has an Rx for Protonix,
but she does not take it every day. Her family hx includes the
presence of DM and HTN.

3. Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN;

4. Maternal and paternal grandparents without known medical
issues; 1 brother and 3 other sisters without known medical
issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with
one man. Works for DEFACS. Reports occasional alcohol
use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are
relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin
discolorations, any changes in lesions

5. Respiratory
Denies cough. Reports dyspnea that accompanies the rare
palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of any kind
Gastrointestinal
Abdominal pain (see HPI) and Hx of GERD. Denies N/V/D,
constipation, appetite changes
Ears
Denies Ear pain, hearing loss, ringing in ears
Genitourinary/Gynecological
Reports burning with urination, but denies frequency or
urgency. Contraceptive and STD prevention includes condoms
with every coital event. Current stable sexual relationship with
one man. Denies known historic or recent STD exposure. Last
PAP was 7/2016 and normal. Regular monthly menstrual cycle
lasting 3-4 days.
Nose/Mouth/Throat

6. Denies sinus problems, dysphagia, nose bleeds or discharge
Musculoskeletal
Denies back pain, joint swelling, stiffness or pain
Breast
Denies SBE
Neurological
Denies syncope, seizures, paralysis, weakness
Heme/Lymph/Endo
Denies bruising, night sweats, swollen glands
Psychiatric
Denies depression, anxiety, sleeping difficulties
OBJECTIVE

7. Weight
140lb
Temp
-97.7
BP
123/82
Height
5’4”
Pulse
74
Respiration
18
General Appearance
Healthy appearing adult female in no acute distress. Alert and
oriented; answers questions appropriately.
Skin
Skin is normal color for ethnicity, warm, dry, clean and intact.

8. No rashes or lesions noted.
HEENT
Head is norm cephalic, hair evenly distributed. Neck: Supple.
Full ROM. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra heart sounds.
Respiratory
Symmetric chest walls. Respirations regular and easy; lungs
clear to auscultation bilaterally.
Gastrointestinal
Abdomen flat; BS active in all 4 quadrants. Abdomen soft,
suprapubic tender. No hepatosplenomegaly.
Genitourinary
Suprapubic tenderness noted. Skin color normal for ethnicity.
Irritation noted at labia majora, minora, and perineum. No
ulcerated lesions noted. Lymph nodes not palpable. Vagina

9. pink and moist without lesions. Discharge minimal, thick,
dark red, no odor. Cervix pink without lesions. No CMT.
Uterus normal size, shape, and consistency.
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the
exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait
normal.
Psychiatric
Alert and oriented. Dressed in clean clothes. Maintains eye
contact. Answers questions appropriately.
Lab Tests
Urinalysis – blood noted (pt. on menstrual period), but results
negative for infection
Urine culture testing unavailable
Wet prep - inconclusive

10. STD testing pending for gonorrhea, chlamydia, syphilis, HIV,
HSV 1 & 2, Hep B & C
Special Tests- No ordered at this time.
Diagnosis
Differential Diagnoses
1-Bacterial Vaginosis (N76.0)
2- Malignant neoplasm of female genital organ,
unspecified. (C57.9)
3-Gonococcal infection, unspecified. (A54.9)
Diagnosis
o Urinary tract infection, site not specified. (N39.0)
Candidiasis of vulva and vagina. (B37.3) secondary to
presenting symptoms (Colgan & Williams, 2011) & (Hainer &
Gibson, 2011).
Plan/Therapeutics

11. Plan
:
Medication
–
§ Terconazole cream 1 vaginal application QHS for 7 days for
Vulvovaginal Candidiasis;
§ Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days
for UTI (Woo & Wynne, 2012)
Education
–
§ Medications prescribed.
§ UTI and Candidiasis symptoms, causes, risks, treatment,
prevention. Reasons to seek emergent care, including N/V,
fever, or back pain.
§ STD risks and preventions.
§ Ulcer prevention, including taking Protonix as prescribed,
not exceeding the recommended dose limit of NSAIDs, and not
taking NSAIDs on an empty stomach.

12. Follow-up
–
§ Pt will be contacted with results of STD studies.
§ Return to clinic when finished the period for perform pap-
smear or if symptoms do not resolve with prescribed TX.