Talking about female genitalia guidelines. Please analyze and Make an Episodic SOAP note.
complete and add to this soap note, you are able to make up what info is missing or add to the info below
For this week, you will analyze the following case study:
CC: dysuria and urinary frequency
HPI: T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.
Tonsillectomy in 2001
Appendectomy in 2020
PMH: UTI 3 years ago
PSHx: Hysterectomy at 25 years
Medication: Tylenol 1000 mg PO every 6 hours for pain
FHx: Mother breast cancer ( alive) Father hypertension (alive)
Social: Single, no tobacco , works as a bartender, positive for ETOH
Allergies: PCN and Sulfa
Review of Symptoms:
General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
Abdominal: Denies nausea and vomiting. No appetite
VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs
Abdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
Diagnostics: Urine specimen collected, STD testing
1 tablet Centrum Multivitamin Daily .
Protonix 20mg PO daily for GERD.
These findings, describe abnormal findings and as a provider develop an episodic note and you are allowed to make up vital signs and related body systems areas for the SOAP note.