SOAP NOTE: Acute Candidiasis of The Vagina

The patient is a 21-year-old female presenting with a three-day history of vaginal itching and a thick, white, odorless discharge resembling cottage cheese. Symptoms began gradually and have worsened over the last two days, especially after exercise or prolonged sitting. She denies dysuria, fever, or pelvic pain. She reports using scented soap and wearing tight leggings regularly. No prior similar episodes reported, and she is not currently sexually active.

Currently takes a daily multivitamin for general health. No prescription or over-the-counter antifungal medications have been used yet.

No significant past medical history. Reports overall good health and no chronic conditions.

Allergies:

No known drug or food allergies.

Medication Intolerances:

None reported.

Chronic Illnesses/Major traumas

No history of chronic illnesses. No major injuries or trauma.

Hospitalizations/Surgeries

No past hospitalizations or surgeries.

Mother has hypothyroidism. Father has type 2 diabetes. No family history of reproductive, renal, or psychiatric disorders. No history of ovarian or cervical cancer. Siblings are in good health with no chronic illnesses.

The patient is a full-time university student pursuing a degree in education. She lives in an off-campus apartment with two roommates. She is single and not currently in a sexual relationship. No tobacco or recreational drug use. Drinks alcohol occasionally on weekends. Reports feeling safe in her home and campus environment. Exercises regularly and maintains a healthy diet. Denies any current emotional or social stressors.

No weight loss, fatigue, chills, or fever. Energy level is normal.

Denies chest pain, palpitations, edema, or orthopnea.

No rashes, lesions, or changes in moles. No delayed wound healing.

No cough, dyspnea, wheezing, or hemoptysis. No history of TB or pneumonia.

No visual changes or eye discomfort. No corrective lenses used.

No nausea, vomiting, constipation, or abdominal pain. Regular bowel movements.

No ear pain, hearing loss, or discharge.

Reports intense vaginal itching and thick, white, odorless discharge. Denies dysuria or urgency. No known STDs. The last menstrual period was two weeks ago, with a regular flow. Not sexually active. The last pap smear was one year ago, and the results were normal. No history of pregnancy.

No sore throat, nasal congestion, or bleeding. Good dental hygiene.

No joint pain, swelling, or stiffness. No history of bone or muscle injury.

Performs monthly self-exams. No pain, lumps, or nipple discharge noted.

No dizziness, weakness, seizures, or blackout spells.

No night sweats, swollen glands, bruising, or abnormal bleeding. No endocrine complaints. HIV negative.

Denies depression, anxiety, or sleep disturbances. No psychiatric history.

Healthy, alert, and cooperative. Answers questions clearly.

Warm, dry, no visible rashes.

Normocephalic, no lesions. Eyes PERRLA, EOMI. TM clear. Oral mucosa is moist. No lymphadenopathy.

Normal S1/S2 with regular rate and rhythm, no murmurs. Pulses 3+ bilaterally. No edema.

Lungs are clear bilaterally, no wheezes or rales.

Soft, non-tender abdomen. Bowel sounds are active.

Normal exam, no abnormalities.

External genitalia normal. Vaginal walls pink with thick white discharge. Cervix pink, no lesions, and nulliparous. No CMT or adnexal tenderness. No uterine or ovarian masses palpated.

Full ROM, no joint swelling.

Alert, oriented, normal gait and balance.

Normal mood and affect. Clear speech, logical thought process.

Wet prep: Pending

Urine culture: Pending

Vaginal pH: 4.0 (acidic)

No special tests ordered

o    1- Acute vaginitis (N76.0) – Considered due to vaginal discharge and itching, but absence of foul odor or irritation with urination makes it less likely (Hildebrand et al., 2025).

o    2- Gonococcal infection of lower genitourinary tract (A54.01) – Considered due to discharge but unlikely due to lack of sexual activity and negative STD history (National Library of Medicine, n.d.).

o   3- Trichomoniasis, unspecified (A59.9) – Typically presents with frothy green-yellow discharge and fishy odor; not observed here (Schumann & Plasner, 2023).

Diagnosis

o    Acute candidiasis of the vulva and vagina (Vaginal yeast infection) (B37.3) – The diagnosis is based on the patient’s report of intense vaginal itching and thick, white, odorless discharge resembling cottage cheese, which are classic signs of candidiasis (Jeanmonod et al., 2024). Physical exam confirmed the presence of this discharge with mild vaginal irritation, and vaginal pH was acidic, which supports a fungal cause. The absence of foul odor, dyspareunia, or urinary symptoms helps rule out bacterial vaginosis and STIs.

§  Further Testing- Await results of wet prep and culture for confirmation.

§  Medication- Initiate Fluconazole 150 mg orally once.

§  Education- Advice on completing antifungal treatment and avoiding tight-fitting, synthetic clothing. Instructed on proper perineal hygiene. Avoid douching and scented soaps.

§  Non-medication treatments- Recommend probiotic-rich foods like yogurt.

§  Follow-up in seven days to check if symptoms persist or worsen.

The patient tolerated the exam well. She appeared knowledgeable and engaged in the care discussion. She expressed relief upon understanding the condition and treatment plan. A follow-up visit is scheduled if symptoms do not resolve after medication.