SOAP NOTE ON UTI (URETHRITIS) 2 Sex: Female Age: 26 CC: “I have burning urination and unusual vaginal discharge.”

Document Content and Description Below

SOAP NOTE ON UTI (URETHRITIS) 2 Sex: Female Age: 26 CC: “I have burning urination and unusual vaginal discharge.” HPI: Patient is 26 years old and she presents to the office with a chief ... complain of burning urination and unusual vaginal discharge. Patient says that the symptoms started five days ago and have been aggravating with time. She adds that she has been having smelly vaginal discharge and adds that she has not noted any changes with her menstruation Patient adds that she has a new boyfriend of one month whom she has been having unprotected sex with. She denies increased frequency and urgency of urination, pelvic pressure, pain in the lower abdomen, and blood in urine. She denies past diagnosis of urinary tract infections and sexually transmitted diseases. Medication: None. PMH: Immunization: Influenza vaccination is up to date. Other vaccinations are also up to date. Allergies: None. Medication intolerance: None. Hospitalization and Surgeries: Knee surgery after falling during sports 12 years ago. Chronic ailments: None. Family History: Mother and sister have asthma and father has no known chronic ailment. Social History: Denies alcohol, smoking, vaping and drugs abuse. Enjoys spending weekends with family and friends, while going out for walks and watching movies. Works as an accountant in a private firm and has a degree in counting. Stays with a lady friend as her roommate in an apartment in town. ROS SOAP NOTE ON UTI (URETHRITIS) 3 General: Denies fever, shaking, chills, and body pains, sweating at night, malaise, fatigue and increased or decreased energy levels. Respiratory: Denies loud breathing, fast or slow respirations, breathing difficulties and dry coughs or coughs with mucus. Breasts: Denies lumps, pain, itchiness, discharge from the nipple, changes in moles, lesions, and discoloration. Cardiovascular: Denies fast or slow hear rates, palpitations, chest pressure, tightness, tenderness and pain. Heme/Lymph/Endo: Denies sweating at night, abrupt changes in weight, increased or decrease thirst or hunger and changes in energy levels. Gastrointestinal: Denies nausea, vomiting, black tarry stool, diarrhea, constipation, lower abdominal pain and ulcers. Musculoskeletal: Denies upper back and side pain, pelvic pain and pelvic pressure. Genitourinary: Reports smelly unusual vaginal discharge and burning urination and denies urgent and frequent urination and blood in the urine. Also denies cloudy urine. Neurological: Denies shaking, tremors, syncope, fainting and dizziness. Psychiatric: Denies extreme anxiety, excess worry, depression, and stress. OBJECTIVE DATA Weight: 141 lbs BMI: 22.1 kg/m2 Pulse: 85 Resp: 16 Height: 5’ 7” Temp: 98.2 BP: 115/71 General Appearance: Patient looks well nourished and well built. He is in no severe distress and he is attentive. He is dressed in clean and decent clothes which are appropriate of the weather. Breasts: Free of masses, lesions, lumps, swelling, discharge, discolorations and changes in moles. Cardiovascular: Heart rate and rhythm are regular and pulse is normal. Extra sounds are absent. Respiratory: Respirations are easy and of normal rate and rhythm and chest wall is symmetrical. Wheezes are absent Musculoskeletal: Lower and upper back pains are absent. Upper back and side pain are absent. Pelvic pain is absent. Gastrointestinal: Abdomen is not tender, swollen and masses are a [Show More]

Last updated: 1 year ago

Preview 1 out of 6 pages