Table 1
Table 2
Term Definition
Sexuality
Sexual health
Sexual identity
Sexual orientation
Sexual agency
Sex
Gender Identity
Transgender
Gender dysphoria
Cisgender
Transmale
Transfemale
Name 5 medical (physical) causes
of female sexual dysfunction
Name 5 medication-induced
sexual dysfunction
Table 3
Gayle is a 25-year-old woman who comes to your office for her first Pap smear exam. She tried to
have a Pap smear before, but she was unable to tolerate insertion of the speculum. She cannot use
tampons during her menses due to pain at her introitus when she tries to insert the tampon. Her last
boyfriend broke up with her after 6 months because she was unable to have intercourse with him
due to pain at her introitus when trying to insert his penis. The patient cannot remember exactly
when this pain started because she didn’t attempt to use tampons until she was 19 years old. She
did not attempt intercourse until she was 21 years old. She thinks she noticed this pain the first time
she attempted to insert a tampon but cannot be sure. She is extremely anxious and almost in tears
about the thought of having a Pap smear, but thinks she “must” have one even though she reports
being unable to ever have vaginal intercourse.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these
questions in your SOAP note.
1. Subjective:
a. How will you approach this patient?
b. What other relevant questions should you ask regarding the HPI?
c. What other medical history questions should you ask?
d. What other social history questions should you include? What potential situation
should you address or be suspicious of?
e. What other family history questions should you ask?
2. Objective:
a. Write a detailed focused physical assessment on this patient.
Name 5 psychological cases of
female sexual dysfunction
Name at least 4 management plan
to help with sexual dysfunction
(include 2 pharmacologic and 2
non pharmacologic interventions)
Define Vulvodynia
Define Vaginismus
What is the difference between the 2 diagnoses?
What are treatment options?
b. Is a pap smear necessary for this patient? Why?
c. Explain what other test(s) you will order and perform, and discuss your rationale for
ordering and performing each test.
3. Assessment/ Diagnosis:
a. What is your presumptive diagnosis? Why?
b. Any other diagnosis or differential diagnosis you would like to add?
4. Plan:
a. How will you manage this patient? What interventions would you suggest?
b. Are there any treatment or medication would you prescribe and why?
c. Explain treatment/management guidelines including any possible side effects and/or
consideration management of the diagnosis.
d. What patient education is important to include for this patient? (Consider including
pharmacological, supplements, and non pharmacological recommendations and
education)
e. What is the follow-up plan of care?
SOAP NOTE FORMAT
Subjective
CC:
HPI:
Medications:
Allergies:
LMP:
Gyn/OB history:
PMH:
Chronic Illness/ Major trauma:
Family Hx:
Social Hx:
ROS
– List the body systems and provide answers
– (Don’t forget to include Gyn ROS)
– You can include questions here that you’d like to ask the patient
Objective Data
General- provide findings
VS
List body systems- provide findings
– (Don’t forget Gyn System)
– (You can include answers here to questions posed in the prompt)
Include POCT (Point of Care testing) not labs that you will send to the laboratoryAssessment/
DiagnosisInclude the ICD10 code
DDX
Plan
Diagnostic tests
Lab Tests
Treatment
Medication
Referrals
Education
Health Maintenance
Follow up
Prompt Questions
(You can include answers here that is asked in the prompt)
