NURSING 101 UTI SOAP NOTE Demographic Information: Patient Initials: J. D. Age: 26 Sex: Male Race: African American Subjective (S). CC: “I have been experiencing pain and burning sensations when urinating”

Document Content and Description Below

NURSING 101 UTI SOAP NOTE Demographic Information: Patient Initials: J. D. Age: 26 Sex: Male Race: African American Subjective (S). CC: “I have been experiencing pain and burning sensatio... ns when urinating” HPI: J. D. is a 26-year-old African American male who presented to the clinic with a one-week history of painful urination and a burning sensation. The pain is aggravated by the urge to urinate and alleviates between urgency episodes and he rates the pain at 4 on a scale of 0-10. The patient also reports having frequent urination, increased urination urge, and mild lower abdominal pains. He reports that the urine is foul-smelling, cloudy but it was not bloodstained. He denies any history of urethral discharge but he is sexually active and practices unprotected sex with multiple sexual partners. There is no history of flank pain, fever, nausea, vomiting, myalgia, or malaise. PMH: He has no known chronic illnesses but he had a herniorrhaphy when he was 5 years old for inguinal hernia. Allergies: He has no known food, drugs, or environmental allergies. Medications: 3 He is currently on oral Tylenol 1g three times a day for the pain. Social history: He denies any history of alcohol intake, smoking, or use of recreational drugs. He lives with a friend and he is an accountant in a local bank. Family history: He is the last born in a family of three, all his siblings are alive but the firstborn is hypertensive. Both parents are alive but the dad is both hypertensive and diabetic while the mother is asthmatic and she is a breast cancer survivor. Health Maintenance/Promotion: He reported that he visits the hospital annually for a checkup and the last visit was 7 months ago. His immunization history is up to date and received pneumococcal and influenza vaccination 2 months ago. He reports that he takes junk foods most of the time but he reports to be taking early morning joggings every day and visits the gym once a week. ROS: General: He denies loss of appetite, general body weakness, fever, chills, excessive sweating, recent weight loss or gain, dizziness, or changes in sleep patterns. HEENT: Head: Denies recent head trauma, headache, dizziness, or loss of appetite. Eye: He denies eye pain or secretions, loss of vision, changes in vision, blurry vision, or double vision. Ear: Denies 4 ear discharge, hearing difficulties, or tinnitus. Nose: Denies nasal congestion, nasal obstruction, sinus pain, postnasal discharge, loss of sense of smell, or nose bleeding. Throat: Denies pain during swallowing, difficulty in swallowing, hoarseness of voice, or a sore throat. [Show More]

Last updated: 1 year ago

Preview 1 out of 10 pages