SOAP NOTE1/15/2015: S: PT is a 28 years old female patient presented to the ER with c/o Muscle pain,vaginal discharge, diarrhea, chest and facial rash, and nausea and vomiting x2 days. Patient has ahistory of IUD placement. O: Blood pressure: 105/62. Temperature: 100.7. respirations: 22.Pulse: 96. Weight: 155. Height: 5’6. Facial erythroderma, warm and clammy. Lungs are normal.Pt is alert but confused to time and place. Pt posture is slightly bent: gait is slow Blood samples,urine, vaginal, and throat cultures obtained. Patient has pain in lower right abdomen. A: Whenquestioned, patient was confused, agitated, and grimacing. UA performed. Lab results showelevated WBCs specific to t-cells, anemia, and albuminuria. Vaginal culture positive for
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Staphylococcus aureus, Toxic shock syndrome, liver function tests