Monroe College NURSING 812  SOAP Note UTI (28 yr old Female)

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Monroe College NURSING 812  SOAP Note UTI (28 yr old Female) SOAP Note UTI Mrs. A is a pleasant, 28 year old, white, female. Referral: none Source and Reliability: Self, reliable source. S (Subj... ective): Chief complaint: “I think I have a urinary track infection.” HPI: Patient states that she began to have symptoms three days ago. She noticed that she was going to the bathroom more than normal. She recalls normal urinary frequency as four times daily, but for the past three days she has felt the urge to go to the bathroom six to eight times daily and has not been able to produce urine every time. She has also experienced increased burning during urination when she is able to produce urine. Yesterday she started to have lower abdominal pain, which worried her so she called the office to make an appointment for today. She states that the pain is worse when she has the urge to go the bathroom and cannot produce any urine. The pain decreases a little between the urgency episodes. The patient rates the pain as a 6/10 today. She says that it has gotten worse every day over the past three days. The patient believes that she has a urinary track infection because she remembers having one a few years ago that presented with the same symptoms. She would like to be treated for her infection because it is hard to watch her children when she is in pain and has to go to the bathroom all the time. Allergies: Penicillin Current Mediation: None. Childhood Illnesses. Chicken Pox. Asthma. Adult Illnesses. Medical & Surgical: Urinary Track Infection age 21. Psychiatric: None Health Maintenance. Immunizations: Patient does not receive regular flu vaccines. Screening tests: Patient does not go to the eye doctors and states that she does not have any trouble with her vision. Patient does not see the dentist regularly, but is going to make an appointment today, for next week, to see one because she is having tooth pain from two broken molars. She had a GYN exam with PAP and STD screening completed during March 2011 at the local health department. Family History: Mother – Lung cancer, heart disease, hypertension, diabetes. Father – Diabetes. Mothers Uncle – Alcoholism. Social History: Patient smokes ½ ppd. Does not drink alcohol. Patient reports a short history of prescription narcotic abuse, but states that she has been clean for two months. She is unemployed, currently staying at home with her two children, ages 1 & 3. She lives with he boyfriend (the father of her children) who works at the chicken processing plant. Exercise & Diet: Patient does not have a regular exercise routine. Patient states that she cooks a lot of prepared frozen food for her and her children or they eat out. Safety Measures: Wears seat belt. ROS: Denies fevers, chills, fatigue, malaise, and headache. Denies ear pain, fullness, popping, loss of hearing, or drainage. Denies blurry vision, eye pain, itching, or drainage. Denies nose drainage, loss of smell, allergies, or sinus pressure. Denies sore throat, loss of taste, difficulty swallowing, and bleeding gums. Patient complains of tooth pain, gum pain, and difficulty chewing. Denies nausea, vomiting, constipation, melena, indigestion, reflux, dysphagia, diarrhea, and loss of appetite. Bilateral lower quadrant abdominal pain/pressure. LMP: 7-14-11, lasting 5 days, normal menstruation for patient. Complains of dysuria, polyuria, burning, frequency, and incomplete bladder emptying, without hematuria, offensive odor of urine, or back/flank pain. Denies chest pain, palpitations, syncope, and shortness of breath. Denies palpitations, orthopnea, and syncope. Denies cough and sputum production. Denies rashes, new moles, itching, acne, or other skin changes. Denies memory loss, imbalance, weakness, and arthritis. [Show More]

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