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SOAP Practice

This 45-year-old female presented with itching and a white, chunky vaginal discharge with burning urination for one week. On examination, her external genitalia were erythematous with a macular rash on the vulva and a thick white vaginal discharge. The differential diagnoses included vulvovaginitis, UTI, diabetes, and pregnancy. The treatment plan was to test for pregnancy, UTI, and thyroid function; perform a wet mount test; discuss a high suspicion for vulvovaginal candidiasis given her recent antibiotic use; and treat with fluconazole.

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Anna Madorskaya
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2K views2 pages

SOAP Practice

This 45-year-old female presented with itching and a white, chunky vaginal discharge with burning urination for one week. On examination, her external genitalia were erythematous with a macular rash on the vulva and a thick white vaginal discharge. The differential diagnoses included vulvovaginitis, UTI, diabetes, and pregnancy. The treatment plan was to test for pregnancy, UTI, and thyroid function; perform a wet mount test; discuss a high suspicion for vulvovaginal candidiasis given her recent antibiotic use; and treat with fluconazole.

Uploaded by

Anna Madorskaya
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Anna Madorskaya

SOAP #1
Iza Ichen

S: This 45 yo Caucasian female is presenting to the office with a chief complaint of itching
between her legs. Pt says that it started about a week ago and that it gets worse when she sweats.
Pt denies that anything makes it better and states that she does have vaginal discharge that looks
white and chunky and that its really red in that area. Pt admits to experiencing slight burning with
urination but denies polyuria, polydipsia, and polyphagia. Pt also denies chills, fever, and night
sweats. Pt says that she experienced similar thing about two years ago but does not recall what it
was. Currently the pt has just finished a course of antibiotics for Bronchitis but does not recall
what medication she was taking. Pt admits to being sexually active and that she has only one
partner, who is not showing any symptoms. Pt admits that she has never been tested for STDs. Pt
admits that she has not had a period for a couple of months but that is normal for her. Pt denies
having any Allergies: Amoxicillin its gives her a rash.

O:
VS:
BP 128/68 mmHg.
R 12 breaths per min/ unlabored.
HR 76 bpm
T 98.8 F, oral
Weight 162 lbs.
Ht 55


The pt is WDWN female, in no apparent distress.
Neck: Supple without any presence of thyromegaly or lymphadenopathy.
Pulm: Clear to auscultaiton
CV: RRR without m/r/g
GI: Abdomen is scaphoid, soft, and non tender. NABS x4 no HSM.
Pelvic: External genitalia is erythamatous and shows macular rash on the vulva. Upon
inspection of the vagina with the speculum a thick white exudate with white parches was
noted that were attached to the vaginal mucosa. The Os was closed and with out a
discharge. During the bimanual exam no cervical motion or adnexal tenderness was
noted. The uterus was normal size.



Differential Diagnosis:
1. Vulvovaginitis
2. UTI
3. DM
4. Pregnancy



Anna Madorskaya
SOAP #1
A/P:
1. Order pregnancy, urine dip, TSH
a. Need to rule out pregnancy, UTI
2. Pregnancy test to rule out pregnancy because the pt has not menstruated in a
couple of months
3. Urine dip to check for glucose to rule out possible DM, and nitrates to rule out
UTI
4. TSH to rule out hypothyroidism
5. Perform a wet mount test with the use of KOH to check of hyphae of Candida,
and at the same time check the vaginal pH
6. Discuss with the patient a high suspicion towards Vulvovaginal candidiasis
a. Educate pt on the etiology of candidal infection after the use of antibiotics.
7. Treat pt with Flucanozole 150mg
a. Take one pill by mouth now
8. Have patient make a follow up appointment if the discharge does not clear up.


Anna Madorskaya PA-S

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