Soap note and chart

Description

Table 1

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Term Definition
Sexuality
Sexual health
Sexual identity
Sexual orientation
Sexual agency
Sex
Gender Identity
Transgender
Gender dysphoria
Cisgender
Transmale
Transfemale
Table 2
Name 5 medical (physical) causes of
female sexual dysfunction
Name 5 medication-induced sexual
dysfunction
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)

Table 3
Define Vulvodynia
Define Vaginismus
What is the difference between the 2 diagnoses?
What are treatment options?

Soap Note
Ty is 22-year-old who comes to your office for an annual physical exam. On the
intake paperwork, you note the gender box is blank. Ty was female assigned as
birth but identifies as They/Them. The patient selected both the “have sex with
females” and the “have sex with males” box in the sexual history.
Answer the following in complete sentences or in question format as if you are
asking the patient these questions:
1. How will you verify the patient’s name and preferred name?
2. How will you ask for the patient’s gender
3. How will you ask for the patient’s preferred pronouns?
Write a brief SOAP note regarding this patient. Make sure to include your answers
to these questions in your SOAP note.

1. Subjective:
a. What other relevant questions should you ask regarding the HPI?
b. What other medical history questions should you ask?
c. What other family history questions should you ask?
d. What other social history questions should you include?

2. Objective:
a. Write a detailed focused physical assessment on this patient.
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. What are some educational considerations should you include in
regarding having a male partner?
b. What are some educational considerations should you include in
regarding having a female partner?
c. Are there any treatment or medication would you prescribe and
why?
d. Explain treatment/management guidelines including any possible
side effects and/or consideration management of the diagnosis.
e. What patient education is important to include for this patient?
(Consider including pharmacological, supplements, and non
pharmacological recommendations and education)