Running head: SOAP NOTE 1
SOAP NOTE 4
|Date: 03-16-2020||Age: 29||Sex: F|
“I am urinating all the time, and it burns when I urinate”
This is a 29-year-old African American woman presenting today to the clinic with continuing complaints of dysuria, urgency to urinate, and frequency of urination. She states that she has recently noticed that her urine has a “foul and unpleasant smell”. The patient also complains of a mild fever. She contends that physical and emotional stress often exacerbate the symptoms.
Allergies: Patient reports no food, environmental, or drug allergies
Medication Intolerances: N/A
Chronic Illnesses/Major traumas: No chronic illnesses or major traumas
Patient’s father currently alive at age 61, diagnosed with cardiac disease.
Mother passed away three years ago from a tragic road accident.
Patient has two older sibling, both of whom are alive and well.
EM works as a sales representative for a fashion designer store in the state. She denies cigarette smoking but admits to social ETOH use and occasional marijuana use. She states that for the past 7 months, she has been sexually active with one male partner. Patient also asserts that for contraception, she uses spermicide-coated condoms
Endorses mild fevers but denies chills, malaise, night sweats, fatigue, or recent weight changes
Patient denies palpitations, claudication, chest pain, or orthopnea
EM denies changes in moles, rashes, itching, easy bruising, or bites
Denies painful breathing, SOB, abnormal sputum production or cough. She does not recall even taking a TB skin test
Denies visual loss, double vision, or blurred vision. She states she has no history of cataracts or glaucoma.
Patient denies abdominal pain, difficulty swallowing, vomiting, intolerance to food, appetite changes, or stool changes
Denies ear pain, ear infections, or tinnitus
Patient does report urgency, frequency, dysuria, odorous urine and suprapubic pain. She reports voiding at least 15 times daily. She nonetheless rebuts flank pain, hematuria and history of STIs. LMP 1 week ago, no heavy bleeding. She confides that she uses spermicide-coated condoms for contraception.
EM denies nasal pain, congestion or other sinus problems. Refutes throat swelling or pain
Denies limits to ROM, swelling, muscle pain, or warm joints
She denies discharge, redness, tenderness or any other breast changes
Patient rebuts coordination difficulties, paralysis, tremors, seizures, or syncope